Managing patients with multimorbidity in primary care

Are older people worse off in 2040 regarding health and resources to deal with it? - Future developments in complex health problems and in the availability of resources to manage health problems in the Netherlands

Introduction

Developing sustainable health policy requires an understanding of the future demand for health and social care. We explored the characteristics of the 65+ population in the Netherlands in 2020 and 2040, focusing on two factors that determine care needs: (1) the occurrence of complex health problems and (2) the availability of resources to manage health and care (e.g., health literacy, social support).

Methods

Estimations of the occurrence of complex health problems and the availability of resources for 2020 were based on registry data and patient-reported data. Estimations for 2040 were based on (a) expected demographic developments, and (b) expert opinions using a two-stage Delphi study with 26 experts from policy making, practice and research in the field of health and social care.

Results

The proportion of people aged 65+ with complex health problems and limited resources is expected to increase from 10% in 2020 to 12% in 2040 based on demographic developments, and to 22% in 2040 based on expert opinions. There was high consensus (>80%) that the proportion with complex health problems would be greater in 2040, and lower consensus (50%) on an increase of the proportion of those with limited resources. Developments that are expected to drive the future changes refer to changes in multimorbidity and in psychosocial status (e.g., more loneliness).

Conclusion

The expected increased proportion of people aged 65+ with complex health problems and limited resources together with the expected health and social care workforce shortages represent large challenges for public health and social care policy.

A hypothesis - generating Swedish extended national cross-sectional family study of multimorbidity severity and venous thromboembolism

OBJECTIVES

Venous thromboembolism (VTE) is a common worldwide disease. The burden of multimorbidity, that is, two or more chronic diseases, has increased. Whether multimorbidity is associated with VTE risk remains to be studied. Our aim was to determine any association between multimorbidity and VTE and any possible shared familial susceptibility.

DESIGN

A nationwide extended cross-sectional hypothesis - generating family study between 1997 and 2015.

SETTING

The Swedish Multigeneration Register, the National Patient Register, the Total Population Register and the Swedish cause of death register were linked.

PARTICIPANTS

2 694 442 unique individuals were analysed for VTE and multimorbidity.

MAIN OUTCOMES AND MEASURES

Multimorbidity was determined by a counting method using 45 non-communicable diseases. Multimorbidity was defined by the occurrence of ≥2 diseases. A multimorbidity score was constructed defined by 0, 1, 2, 3, 4 or 5 or more diseases.

RESULTS

Sixteen percent (n=440 742) of the study population was multimorbid. Of the multimorbid patients, 58% were females. There was an association between multimorbidity and VTE. The adjusted odds ratio (OR) for VTE in individuals with multimorbidity (2 ≥ diagnoses) was 3.16 (95% CI: 3.06 to 3.27) compared with individuals without multimorbidity. There was an association between number of diseases and VTE. The adjusted OR was 1.94 (95% CI: 1.86 to 2.02) for one disease, 2.93 (95% CI: 2.80 to 3.08) for two diseases, 4.07 (95% CI: 3.85 to 4.31) for three diseases, 5.46 (95% CI: 5.10 to 5.85) for four diseases and 9.08 (95% CI: 8.56 to 9.64) for 5 ≥ diseases. The association between multimorbidity and VTE was stronger in males OR 3.45 (3.29 to 3.62) than in females OR 2.91 (2.77 to 3.04). There were significant but mostly weak familial associations between multimorbidity in relatives and VTE.

CONCLUSIONS

Increasing multimorbidity exhibits a strong and increasing association with VTE. Familial associations suggest a weak shared familial susceptibility. The association between multimorbidity and VTE suggests that future cohort studies where multimorbidity is used to predict VTE might be worthwhile.

Multimorbidity patterns and health-related quality of life in Jamaican adults: a cross sectional study exploring potential pathways

Introduction

Multimorbidity and health-related quality of life (HRQoL) are intimately linked. Multiple chronic conditions may adversely affect physical and mental functioning, while poorer HRQoL may contribute to the worsening course of diseases. Understanding mechanisms through which specific combinations of diseases affect HRQoL outcomes can facilitate identification of factors which are amenable to intervention. Jamaica, a middle-income country with high multimorbidity prevalence, has a health service delivery system dominated by public sector provision via a broad healthcare network. This study aims to examine whether multimorbidity classes differentially impact physical and mental dimensions of HRQoL in Jamaicans and quantify indirect effects on the multimorbidity-HRQoL relationship that are mediated by health system factors pertaining to financial healthcare access and service use.

Materials and methods

Latent class analysis (LCA) was used to estimate associations between multimorbidity classes and HRQoL outcomes, using latest available data from the nationally representative Jamaica Health and Lifestyle Survey 2007/2008 (N = 2,551). Multimorbidity measurement was based on self-reported presence/absence of 11 non-communicable diseases (NCDs). HRQoL was measured using the 12-item short-form (SF-12) Health Survey. Mediation analyses guided by the counterfactual approach explored indirect effects of insurance coverage and service use on the multimorbidity-HRQoL relationship.

Results

LCA revealed four profiles, including a Relatively Healthy class (52.7%) characterized by little to no morbidity and three multimorbidity classes characterized by specific patterns of NCDs and labelled Metabolic (30.9%), Vascular-Inflammatory (12.2%), and Respiratory (4.2%). Compared to the Relatively Healthy class, Vascular-Inflammatory class membership was associated with lower physical functioning (β = -5.5; p < 0.001); membership in Vascular-Inflammatory (β = -1.7; p < 0.05), and Respiratory (β = -2.5; p < 0.05) classes was associated with lower mental functioning. Significant mediated effects of health service use, on mental functioning, were observed for Vascular-Inflammatory (p < 0.05) and Respiratory (p < 0.05) classes.

Conclusion

Specific combinations of diseases differentially impacted HRQoL outcomes in Jamaicans, demonstrating the clinical and epidemiological value of multimorbidity classes for this population, and providing insights that may also be relevant to other settings. To better tailor interventions to support multimorbidity management, additional research is needed to elaborate personal experiences with healthcare and examine how health system factors reinforce or mitigate positive health-seeking behaviours, including timely use of services.

Assessing needs-based supply of physicians: a criteria-led methodological review of international studies in high-resource settings

BACKGROUND

Many health systems embrace the normative principle that the supply of health services ought to be based on the need for healthcare. However, a theoretically grounded framework to operationalize needs-based supply of healthcare remains elusive. The aim of this paper is to critically assess current methodologies that quantify needs-based supply of physicians and identify potential gaps in approaches for physician planning. To this end, we propose a set of criteria for consideration when estimating needs-based supply.

METHODS

We conducted searches in three electronic bibliographic databases until March 2020 supplemented by targeted manual searches on national and international websites to identify studies in high-resource settings that quantify needs-based supply of physicians. Studies that exclusively focused on forecasting methods of physician supply, on inpatient care or on healthcare professionals other than physicians were excluded. Additionally, records that were not available in English or German were excluded to avoid translation errors. The results were synthesized using a framework of study characteristics in addition to the proposed criteria for estimating needs-based physician supply.

RESULTS

18 quantitative studies estimating population need for physicians were assessed against our criteria. No study met all criteria. Only six studies sought to examine the conceptual dependency between need, utilization and supply. Apart from extrapolations, simulation models were applied most frequently to estimate needs-based supply. 12 studies referred to the translation of need for services with respect to a physician's productivity, while the rest adapted existing population-provider-ratios. Prospective models for estimating future care needs were largely based on demographic predictions rather than estimated trends in morbidity and new forms of care delivery.

CONCLUSIONS

The methodological review shows distinct heterogeneity in the conceptual frameworks, validity of data basis and modeling approaches of current studies in high-resource settings on needs-based supply of physicians. To support future estimates of needs-based supply, this review provides a workable framework for policymakers in charge of health workforce capacity planning.

Effects of care of multimorbid patients in general practices by advanced practice nurses (FAMOUS): study protocol for a nonrandomized controlled trial

BACKGROUND

Multimorbidity is a common phenomenon among patients treated in general practices. Key challenges within this group include functional difficulties, polypharmacy, treatment burden, fragmentation of care, reduced quality of life and increased health care utilization. These problems cannot be solved in the short consultation time of a general practitioner (GP) since there is an increasing shortage of GPs. In many countries, advanced practice nurses (APNs) are successfully integrated into primary health care for multimorbid patients. The objective of this study is to examine whether the integration of APNs in the primary care of multimorbid patients in Germany leads to optimized care of the target group and to a reduction in the workload of the GPs.

METHODS

The intervention includes the integration of APNs into the care for multimorbid patients in general practice for twelve months. Qualifications for APNs include a master's level academic degree and 500 hours of project-specific training. Their tasks include in-depth assessment, preparation, implementation, monitoring and evaluation of a person-centred and evidence-based care plan. In this nonrandomized controlled trial, a prospective multicentre mixed methods study will be performed. The main inclusion criterion was the cooccurrence of three chronic diseases. For data collection in the intervention group (n = 817), routine data from health insurance companies and association of statutory health insurance physicians (ASHIP) will be used, as well as qualitative interviews. In addition, the intervention will be assessed through documentation of the care process and standardized questionnaires using a longitudinal design. The control group (n = 1634) will receive standard care. For the evaluation, routine data from health insurance companies are matched at a ratio of 1:2. Outcomes will be measured using emergency contacts and GP visits, treatment costs, health status of the patients and the satisfaction of parties involved. The statistical analyses will include Poisson regression to compare outcomes between the intervention and control groups. Descriptive and analytical statistical methods will be used in the longitudinal analysis of the intervention group data. Cost analysis will compare total costs and subgroup costs between the intervention and control groups. Qualitative data will be analysed using content analysis.

DISCUSSION

Challenges to this protocol could include the political and strategic environment as well as the planned number of participants.

TRIAL REGISTRATION

DRKS00026172 on DRKS.

Cardiovascular disease and type 2 diabetes in older adults: a combined protocol for an individual participant data analysis for risk prediction and a network meta-analysis of novel anti-diabetic drugs

Introduction

Older and multimorbid adults with type 2 diabetes (T2D) are at high risk of cardiovascular disease (CVD) and chronic kidney disease (CKD). Estimating risk and preventing CVD is a challenge in this population notably because it is underrepresented in clinical trials. Our study aims to (1) assess if T2D and haemoglobin A1c (HbA1c) are associated with the risk of CVD events and mortality in older adults, (2) develop a risk score for CVD events and mortality for older adults with T2D, (3) evaluate the comparative efficacy and safety of novel antidiabetics.

Methods and analysis

For Aim 1, we will analyse individual participant data on individuals aged ≥65 years from five cohort studies: the Optimising Therapy to Prevent Avoidable Hospital Admissions in Multimorbid Older People study; the Cohorte Lausannoise study; the Health, Aging and Body Composition study; the Health and Retirement Study; and the Survey of Health, Ageing and Retirement in Europe. We will fit flexible parametric survival models (FPSM) to assess the association of T2D and HbA1c with CVD events and mortality. For Aim 2, we will use data on individuals aged ≥65 years with T2D from the same cohorts to develop risk prediction models for CVD events and mortality using FPSM. We will assess model performance, perform internal-external cross validation, and derive a point-based risk score. For Aim 3, we will systematically search randomized controlled trials of novel antidiabetics. Network meta-analysis will be used to determine comparative efficacy in terms of CVD, CKD, and retinopathy outcomes, and safety of these drugs. Confidence in results will be judged using the CINeMA tool.

Ethics and dissemination

Aims 1 and 2 were approved by the local ethics committee (Kantonale Ethikkommission Bern); no approval is required for Aim 3. Results will be published in peer-reviewed journals and presented in scientific conferences.

Instruments Measuring Self-Care and Self-Management of Chronic Conditions by Community-Dwelling Older Adults: A Scoping Review

Given the high prevalence of chronic conditions and multimorbidity in older adults, there is a need to better conceptualize and measure self-care and self-management to promote a person-centered approach. This scoping review aimed to identify and map instruments measuring self-care and self-management of chronic conditions by older adults. We searched six electronic databases, charted data from the studies and tools and reported the results in accordance with the PRISMA-ScR guidelines. A total of 107 articles (103 studies) containing 40 tools were included in the review. There was substantial variation in the tools in terms of their aims and scope, structure, theoretical foundations, how they were developed, and the settings in which they have been used. The quantity of tools demonstrates the importance of assessing self-care and self-management. Consideration of the purpose, scope, and theoretical foundation should guide decisions about tools suitable for use in research and clinical practice.

Global and regional prevalence of multimorbidity in the adult population in community settings: a systematic review and meta-analysis

BACKGROUND

Knowing the prevalence of multimorbidity among adults across continents is a crucial piece of information for achieving Sustainable Development Goal 3.4, which calls for reducing premature death due to non-communicable diseases. A high prevalence of multimorbidity indicates high mortality and increased healthcare utilization. We aimed to understand the prevalence of multimorbidity across WHO geographic regions among adults.

METHODS

We performed a systematic review and meta-analysis of surveys designed to estimate the prevalence of multimorbidity among adults in community settings. We searched PubMed, ScienceDirect, Embase and Google Scholar databases for studies published between January 1, 2000, and December 31, 2021. The random-effects model estimated the pooled proportion of multimorbidity in adults. Heterogeneity was quantified using I² statistics. We performed subgroup analyses and sensitivity analyses based on continents, age, gender, multimorbidity definition, study periods and sample size. The study protocol was registered with PROSPERO (CRD42020150945).

FINDINGS

We analyzed data from 126 peer-reviewed studies that included nearly 15.4 million people (32.1% were male) with a weighted mean age of 56.94 years (standard deviation of 10.84 years) from 54 countries around the world. The overall global prevalence of multimorbidity was 37.2% (95% CI = 34.9-39.4%). South America (45.7%, 95% CI = 39.0-52.5) had the highest prevalence of multimorbidity, followed by North America (43.1%, 95% CI = 32.3-53.8%), Europe (39.2%, 95% CI = 33.2-45.2%), and Asia (35%, 95% CI = 31.4-38.5%). The subgroup study highlights that multimorbidity is more prevalent in females (39.4%, 95% CI = 36.4-42.4%) than males (32.8%, 95% CI = 30.0-35.6%). More than half of the adult population worldwide above 60 years of age had multimorbid conditions (51.0%, 95% CI = 44.1-58.0%). Multimorbidity has become increasingly prevalent in the last two decades, while the prevalence appears to have stayed stable in the recent decade among adults globally.

INTERPRETATION

The multimorbidity patterns by geographic regions, time, age, and gender suggest noticeable demographic and regional differences in the burden of multimorbidity. According to insights about prevalence among adults, priority is required for effective and integrative interventions for older adults from South America, Europe, and North America. A high prevalence of multimorbidity among adults from South America suggests immediate interventions are needed to reduce the burden of morbidity. Furthermore, the high prevalence trend in the last two decades indicates that the global burden of multimorbidity continues at the same pace. The low prevalence in Africa suggests that there may be many undiagnosed chronic illness patients in Africa.

FUNDING

None.

Multimorbidity in People with Epilepsy

Multimorbidity is an emerging priority in healthcare due to associations with the ageing population, frailty, polypharmacy, health and social care demands. It affects 60-70% of adults and 80% of children with epilepsy. Neurodevelopmental conditions are commonly seen in children with epilepsy, while cancer, cardiovascular and neurodegenerative conditions often afflict older people with epilepsy. Mental health problems are common across the lifespan. Genetic, environmental, social and lifestyle factors contribute to multimorbidity and its consequences. Multimorbid people with epilepsy (PWE) are at higher risk of depression and suicide, premature death, suffer lower health-related quality of life, and require more hospital admissions and health care costs. The best management of multimorbid PWE requires a paradigm shift from the traditional single disease-single comorbidity approach and a refocus on a person-centred approach. Improvements in health care must be informed by assessing the burden of multimorbidity associated with epilepsy, delineating disease clusters, and measuring the effects on health outcomes.

Identification of polypharmacy patterns in new-users of metformin using the Apriori algorithm: A novel framework for investigating concomitant drug utilization through association rule mining

PURPOSE

With increased concomitant chronic diseases in type 2 diabetes mellitus (T2DM), the use of multiple drugs increases as well as the risk of drug-drug interactions (DDI) and adverse drug reactions (ADR). Nevertheless, how medication patterns vary in T2DM patients across different sex and age groups is unclear. This study aims to identify and quantify common drug combinations in first-time metformin users with polypharmacy (≥5 co-medications).

METHODS

New users of metformin were identified from the IQVIA Medical Research Data incorporating data from THIN, A Cegedim Database (2016-2019). A descriptive cohort study explored prescription patterns in patients with polypharmacy. The Apriori algorithm, used to find frequent item-sets in databases, was first-time applied to identify and quantify drug combinations of up to seven drugs to investigate potential harmful polypharmacy patterns.

RESULTS

The cohort included 34 169 new-users of metformin, of which 20 854 (61.0%) received polypharmacy. Atorvastatin was the most frequently co-prescribed drug with metformin overall (38.7%), in women (34.3%) and men (42.6%). In the stratified analysis, a higher proportion of women received polypharmacy (65.6%) compared to men (57.4%). Moreover, the proportion of patients receiving polypharmacy increased with age (18-39 years = 30.4%, 40-59 years = 50.5%, 60-74 years = 70.9%, and ≥75 years = 84.3%).

CONCLUSION

This study is the first to identify and quantify commonly prescribed combinations of drugs compounds in patients with polypharmacy using the Apriori algorithm. The high polypharmacy prevalence at all strata indicates the need to optimize polypharmacy to minimize DDI and ADR.

A scoping review of evidence-based guidance and guidelines published by general practice professional organizations

BACKGROUND

General practitioners (GPs) need robust, up-to-date evidence to deliver high-quality patient care. There is limited literature regarding the role of international GP professional organizations in developing and publishing clinical guidelines to support GPs clinical decision making.

OBJECTIVE

To identify evidence-based guidance and clinical guidelines produced by GP professional organizations and summarize their content, structure, and methods of development and dissemination.

METHODS

Scoping review of GP professional organizations following Joanna Briggs Institute guidance. Four databases were searched and a grey literature search was conducted. Studies were included if they were: (i) evidence-based guidance documents or clinical guidelines produced de novo by a national GP professional organization, (ii) developed to support GPs clinical care, and (iii) published in the last 10 years. GP professional organizations were contacted to provide supplementary information. A narrative synthesis was performed.

RESULTS

Six GP professional organizations and 60 guidelines were included. The most common de novo guideline topics were mental health, cardiovascular disease, neurology, pregnancy and women's health and preventive care. All guidelines were developed using a standard evidence-synthesis method. All included documents were disseminated through downloadable pdfs and peer review publications. GP professional organizations indicated that they generally collaborate with or endorse guidelines developed by national or international guideline producing bodies.

CONCLUSION

The findings of this scoping review provide an overview of de novo guideline development by GP professional organizations and can support collaboration between GP organizations worldwide thus reducing duplication of effort, facilitating reproducibility, and identifying areas of standardization.

PROTOCOL REGISTRATION

Open Science Framework: https://doi.org/10.17605/OSF.IO/JXQ26.

Development of a Person-Centred Integrated Care Approach for Chronic Disease Management in Dutch Primary Care: A Mixed-Method Study

To reduce the burden of chronic diseases on society and individuals, European countries implemented chronic Disease Management Programs (DMPs) that focus on the management of a single chronic disease. However, due to the fact that the scientific evidence that DMPs reduce the burden of chronic diseases is not convincing, patients with multimorbidity may receive overlapping or conflicting treatment advice, and a single disease approach may be conflicting with the core competencies of primary care. In addition, in the Netherlands, care is shifting from DMPs to person-centred integrated care (PC-IC) approaches. This paper describes a mixed-method development of a PC-IC approach for the management of patients with one or more chronic diseases in Dutch primary care, executed from March 2019 to July 2020. In Phase 1, we conducted a scoping review and document analysis to identify key elements to construct a conceptual model for delivering PC-IC care. In Phase 2, national experts on Diabetes Mellitus type 2, cardiovascular diseases, and chronic obstructive pulmonary disease and local healthcare providers (HCP) commented on the conceptual model using online qualitative surveys. In Phase 3, patients with chronic conditions commented on the conceptual model in individual interviews, and in Phase 4 the conceptual model was presented to the local primary care cooperatives and finalized after processing their comments. Based on the scientific literature, current practice guidelines, and input from a variety of stakeholders, we developed a holistic, person-centred, integrated approach for the management of patients with (multiple) chronic diseases in primary care. Future evaluation of the PC-IC approach will show if this approach leads to more favourable outcomes and should replace the current single-disease approach in the management of chronic conditions and multimorbidity in Dutch primary care.

How Can a Bundled Payment Model Incentivize the Transition from Single-Disease Management to Person-Centred and Integrated Care for Chronic Diseases in the Netherlands?

To stimulate the integration of chronic care across disciplines, the Netherlands has implemented single-disease management programmes (SDMPs) in primary care since 2010; for example, for COPD, type 2 diabetes mellitus, and cardiovascular diseases. These disease-specific chronic care programmes are funded by bundled payments. For chronically ill patients with multimorbidity or with problems in other domains of health, this approach was shown to be less fit for purpose. As a result, we are currently witnessing several initiatives to broaden the scope of these programmes, aiming to provide truly person-centred integrated care (PC-IC). This raises the question if it is possible to design a payment model that would support this transition. We present an alternative payment model that combines a person-centred bundled payment with a shared savings model and pay-for-performance elements. Based on theoretical reasoning and results of previous evaluation studies, we expect the proposed payment model to stimulate integration of person-centred care between primary healthcare providers, secondary healthcare providers, and the social care domain. We also expect it to incentivise cost-conscious provider-behaviour, while safeguarding the quality of care, provided that adequate risk-mitigating actions, such as case-mix adjustment and cost-capping, are taken.

Time-to-Event Analysis of Factors Influencing Delay in Discharge from a Subacute Complex Discharge Unit during the First Year of the Pandemic (2020) in an Irish Tertiary Centre Hospital

Our study aimed to analyse delaying factors amongst patients with a length of stay (LOS) > 15 days during the COVID-19 pandemic using time-to-event analysis. A total of 390 patients were admitted between March 2020-February 2021 to the subacute complex discharge unit in St James's Hospital: 326 (83.6%) were >65 years of age and 233 (59.7%) were female. The median (IQR) age was 79 (70-86) years with a median (IQR) of 19.4 (10-41) days. A total of 237 (60.7%) events were uncensored, with LOS > 15 days, of which 138 (58.2%) were female and 124 (52.32%) had >4 comorbidities; 153 (39.2%) were censored into LOS ≤ 15 days, and death occurred in 19 (4.8%). Kaplan-Meier's plot compared factors causing a delay in discharge to the single factors: age, gender, and multimorbidity. A multivariate Cox regression analysis adjusted to age, gender, and multimorbidity predicted factors affecting LOS. Further research is required to explore multimorbidity as a risk factor for mortality in patients with prolonged LOS within a complex discharge unit and target gender-specific frailty measures to achieve high-quality patient management.

Development and validation of two versions of the Nurse-Patient Mutuality in Chronic Illness scale

AIMS

The aim of the study was to develop and psychometrically test the Nurse-Patient Mutuality in Chronic Illness (NPM-CI) scale in two versions, one for nurses and one for patients.

METHOD

A multiphase methodological study was conducted. In the first phase, a qualitative investigation was conducted through interviews and an analysis of the content; inductively, the items of two instruments were generated, one for nurses and one for patients. In the second phase, the content and face validity were assessed through the expert consensus method. In the third phase, exploratory factor analysis (EFA), Cronbach's alpha test, intraclass correlation and Pearson correlation coefficients were conducted to estimate construct, criterion validity and instrument reliability. For each phase, the sample included nurses and patients recruited from a large hospital in Northern Italy. Data collection was conducted between June and September 2021.

RESULTS

Nurse and patient versions of the NPM-CI scale were developed. Two rounds of consensus reduced the items from 39 to 20; content validity index ranged between 0.78 and 1, content validity ratio was 0.94. Face validity indicated clarity and comprehensibility of the items. EFA identified three latent factors for both the scales. Internal consistency was satisfactory, with Cronbach's alphas ranging between .80 and .90. Test-retest stability was suggested, with an intraclass correlation coefficient of .96 (nurse scale) and .97 (patient scale). Predictive validity was established, with a Pearson correlation coefficient of .43 (nurse scale) and 0.55 (patient scale) between the mutuality scales and satisfaction in providing and receiving care.

CONCLUSION

The results suggest that the NPM-CI scales are sufficiently valid and reliable for the clinical practice among chronic illness patients and the nurses caring for them. A more in-depth exploration of this construct in the context of nursing and patient outcomes is warranted.

PATIENT OR PUBLIC CONTRIBUTION

Patients were involved in all study phases.

IMPACT

Mutuality is fundamental in the relationship between nurse and patient, based on trust, equality, reciprocity, and mutual respect. The NPM-CI scale was developed and psychometric estimated through a multiphase study in both nurse and patient versions. The NPM-CI scale measures the factors of 'developing and going beyond', 'being the point of reference' and 'deciding and sharing care'. The NPM-CI scale allows us to measure mutuality in clinical practice and research. Expected outcomes and influencing factors for patients and nurses could be associated.

The prevalence of cardiometabolic multimorbidity and its associations with health outcomes among women in China

Objective

In China, a limited number of studies focus on women and examine the effect of cardiometabolic multimorbidity (defined as the presence of two or more cardiometabolic diseases) on health outcomes. This research aims to investigate the epidemiology of cardiometabolic multimorbidity and the association of cardiometabolic multimorbidity with long-term mortality.

Methods

This study used data from the China Health and Retirement Longitudinal Study between 2011 and 2018, which includes 4,832 women aged 45 years and older in China. Poisson-distributed Generalized Linear Models (GLM) were applied to examine the association of cardiometabolic multimorbidity with all-cause mortality.

Results

Overall, the prevalence of cardiometabolic multimorbidity was 33.1% among the total sample of 4,832 Chinese women, and increased with age, ranging from 28.5% (22.1%) for those aged 45-54 years to 65.3% (38.2%) for those aged ≥75 years in urban (rural) areas. Compared with the group of none and single disease, cardiometabolic multimorbidity was positively associated with all-cause death (RR = 1.509, 95% CI = 1.130, 2.017), after adjusting socio-demographic and lifestyle behavioral covariates. Stratified analyses revealed that the association between cardiometabolic multimorbidity and all-cause death was only statistically significant (RR = 1.473, 95% CI = 1.040, 2.087) in rural residents, but not significant in urban residents.

Conclusion

Cardiometabolic multimorbidity is common among women in China and has been associated with excess mortality. Targeted strategies and people-centered integrated primary care models must be considered to more effectively manage the cardiometabolic multimorbidity shift from focusing on single-disease.

Evaluation of Satisfaction with Healthcare Services in Multimorbid Patients Using PACIC+ Questionnaire: A Cross-Sectional Study

Background and Objectives: Although multimorbidity poses many challenges for both individuals and healthcare systems, information on how these patients assess the quality of their healthcare is lacking. This study assessed the multimorbid patients' satisfaction with their healthcare. Materials and Methods: This cross-sectional study was a part of a project Joint Action-Chronic Diseases and Promoting Healthy Ageing across the Life Cycle and its implementation. The study included 400 patients with arterial hypertension and at least one concomitant chronic disease. Patients completed The Patient Assessment of Care for Chronic Conditions Plus (PACIC+) questionnaire, EuroQol Five-Dimensions-Three-Level Quality of Life questionnaire, and Hospital Anxiety and Depression scale. Results: The mean age of the participants was 65.38 years; there were 52.5% women. The mean PACIC+ 5As summary score was 3.60. With increasing age, participants rated worse on most PACIC+ subscales. Participants who assessed their quality of life as worse were also less satisfied with their healthcare. The presence of three or more concomitant diseases negatively affected PACIC+ scores. Patients with ischemic heart disease and heart failure had lower PACIC+ scores on most subscales, whereas patients with atrial fibrillation had lower scores only on the Agree subscale. The presence of diabetes was not associated with worse PACIC+ scores; moreover, the scores in Assist and Arrange subscales were even better in diabetic patients (3.36 vs. 2.80, p = 0.000 and 3.69 vs. 3.13, p = 0.008, respectively). Patients with chronic obstructive pulmonary disease, asthma, and musculoskeletal disorders showed lower PACIC+ scores. Conclusions: Older age, worse self-assessed health state, presence of three or more diseases, and certain chronic diseases were associated with lower patients' satisfaction with their healthcare. Personalized healthcare, increasing competencies of primary healthcare teams, healthcare services accessibility, and financial motivation of healthcare providers may increase multimorbid patients' satisfaction with their healthcare.

Ethnic inequalities in the impact of COVID-19 on primary care consultations: a time series analysis of 460,084 individuals with multimorbidity in South London

BACKGROUND

The COVID-19 pandemic caused rapid changes in primary care delivery in the UK, with concerns that certain groups of the population may have faced increased barriers to access. This study assesses the impact of the response to the COVID-19 pandemic on primary care consultations for individuals with multimorbidity and identifies ethnic inequalities.

METHODS

A longitudinal study based on monthly data from primary care health records of 460,084 patients aged ≥18 years from 41 GP practices in South London, from February 2018 to March 2021. Descriptive analysis and interrupted time series (ITS) models were used to analyse the effect of the pandemic on primary care consultations for people with multimorbidity and to identify if the effect varied by ethnic groups and consultation type.

RESULTS

Individuals with multimorbidity experienced a smaller initial fall in trend at the start of the pandemic. Their primary care consultation rates remained stable (879 (95% CI 869-890) per 1000 patients in February to 882 (870-894) March 2020), compared with a 7% decline among people without multimorbidity (223 consultations (95% CI 221-226) to 208 (205-210)). The gap in consultations between the two groups reduced after July 2020. The effect among individuals with multimorbidity varied by ethnic group. Ethnic minority groups experienced a slightly larger fall at the start of the pandemic. Individuals of Black, Asian, and Other ethnic backgrounds also switched from face-to-face to telephone at a higher rate than other ethnic groups. The largest fall in face-to-face consultations was observed among people from Asian backgrounds (their consultation rates declined from 676 (659-693) in February to 348 (338-359) in April 2020), which may have disproportionately affected their quality of care.

CONCLUSIONS

The COVID-19 pandemic significantly affected primary care utilisation in patients with multimorbidity. While there is evidence of a successful needs-based prioritisation of multimorbidity patients within primary care at the start of the pandemic, inequalities among ethnic minority groups were found. Strengthening disease management for these groups may be necessary to control widening inequalities in future health outcomes.

Multimorbidity and Complexity Among Patients with Cancer in Ontario: A Retrospective Cohort Study Exploring the Clustering of 17 Chronic Conditions with Cancer

BACKGROUND

Multimorbidity is a concern for people living with cancer, as over 90% have at least one other condition. Multimorbidity complicates care coming from multiple providers who work within separate, siloed systems. Information describing high-risk and high-cost disease combinations has potential to improve the experience, outcome, and overall cost of care by informing comprehensive care management frameworks. This study aimed to identify disease combinations among people with cancer and other conditions, and to assess the health burden associated with those combinations to help healthcare providers more effectively prioritize and coordinate care.

METHODS

We used a population-based retrospective cohort design including adults with a cancer diagnosis between March-2003 and April-2013, followed-up until March 2018. We used observed disease combinations defined by level of multimorbidity and partitive (k-means) clusters, ie groupings of similar diseases based on the prevalence of each condition. We assessed disease combination-associated health burden through health service utilization, including emergency department visits, primary care visits and hospital admissions during the follow-up period.

RESULTS

549,248 adults were included in the study. Anxiety, diabetes mellitus, hypertension, and osteoarthritis co-occurred with cancer 1.1 to 5.3 times more often than expected by chance. Disease combinations varied by cancer type and age but were similar between sexes. The largest partitive cluster included cancer and anxiety, with at least 25% of individuals also having osteoarthritis. Cancer also tended to co-occur with hypertension (8.0%) or osteoarthritis (6.2%). There were differences between clusters in healthcare utilization, regardless of the number of disease combinations or clustering approach used.

CONCLUSION

Researchers, clinicians, policymakers, and other stakeholders can use the clustering information presented here to improve the healthcare system for people with cancer multimorbidity by developing cluster-specific care management and clinical guidelines for common disease combinations.

Multimorbidity and out-of-pocket expenditure on medicine in Europe: Longitudinal analysis of 13 European countries between 2013 and 2015

Background

Many European Health Systems are implementing or increasing levels of cost-sharing for medicine in response to the growing constrains on public spending on health despite their negative impact on population health due to delay in seeking care.

Objective

This study aims to examine the relationships between multimorbidity (two or more coexisting chronic diseases, CDs), complex multimorbidity (three or more CDs impacting at least three different body systems), and out-of-pocket expenditure (OOPE) for medicine across European nations.

Methods

This study utilized data on participants aged 50 years and above from two recent waves of the Survey of Health, Aging, and Retirement in Europe conducted in 2013 (n = 55,806) and 2015 (n = 51,237). Pooled cross-sectional and longitudinal study designs were used, as well as a two-part model, to analyse the association between multimorbidity and OOPE for medicine.

Results

The prevalence of multimorbidity was 50.4% in 2013 and 48.2% in 2015. Nearly half of those with multimorbidity had complex multimorbidity. Each additional CD was associated with a 34% greater likelihood of incurring any OOPE for medicine (Odds ratio = 1.34, 95% CI = 1.31-1.36). The average incremental OOPE for medicine was 26.4 euros for each additional CD (95% CI = 25.1-27·7), and 32.1 euros for each additional body system affected (95% CI 30.6-33.7). In stratified analyses for country-specific quartiles of household income the average incremental OOPE for medicine was not significantly different across groups.

Conclusion

Between 2013 and 2015 in 13 European Health Systems increased prevalence of CDs was associated with greater likelihood of having OOPE on medication and an increase in the average amount spent when one occurred. Monitoring this indicator is important considering the negative association with treatment adherence and subsequent effects on health.

Association of multimorbidity with the use of health information technology

Objective

To examine the association of multimorbidity with health information technology use among adults in the USA.

Methods

We used cross-sectional study design and data from the Health Information National Trends Survey 5 Cycle 4. Health information technology use was measured with ten variables comprising access, recent use, and healthcare management. Unadjusted and adjusted logistic and multinomial logistic regressions were used to model the associations of multimorbidity with health information technology use.

Results

Among adults with multimorbidity, health information technology use for specific purposes ranged from 37.8% for helping make medical decisions to 51.7% for communicating with healthcare providers. In multivariable regressions, individuals with multimorbidity were more likely to report general use of health information technology (adjusted odds ratios  =  1.48, 95% confidence intervals  =  1.01-2.15) and more likely to use health information technology to check test results (adjusted odds ratios  =  1.85, 95% confidence intervals  =  1.33-2.58) compared to adults with only one chronic condition, however, there were no significant differences in other forms of health information technology use. We also observed interactive associations of multimorbidity and age on various components of health information technology use. Compared to younger adults with multimorbidity, older adults (≥ 65 years of age) with multimorbidity were less likely to use almost all aspects of health information technology.

Conclusion

Health information technology use disparities by age and multimorbidity were observed. Education and interventions are needed to promote health information technology use among older adults in general and specifically among older adults with multimorbidity.

An analysis of socioeconomic factors on multiple chronic conditions and its economic burden: evidence from the National Health Service Survey in Yunnan Province, China

Background

The economic burden of multiple chronic conditions (MCCs) and its socio-economic influencing factors have widely raised public concerns. However, there are few large population-based studies on these problems in China. Our study aims at determining the economic burden of MCCs and associated factors specific to multimorbidity among middle-aged and older individuals.

Methods

As our study population, we extracted all 11,304 participants over 35 years old from the 2018 National Health Service Survey (NHSS) in Yunnan. Economic burden and socio-demographic characteristics were analyzed with descriptive statistics. Chi-square test and generalized estimating equations (GEE) regression models were used to identify influencing factors.

Results

The prevalence of chronic diseases was 35.93% in 11,304 participants and the prevalence of MCCs increased with age, was 10.12%. Residents who lived in rural areas were more likely to report MCCs than those who lived in urban areas (adjusted OR = 1.347, 97.5% CI: 1.116-1.626). Ethnic minority groups were less likely to report MCCs than those of Han (OR = 0.752, 97.5% CI: 0.601-0.942). Overweight or obese people were more likely to report MCCs than people with normal weight (OR = 1.317, 97.5% CI: 1.099-1.579). The per capita expenses of 2 weeks' illness, per capita hospitalization expenses, annual household income, annual household expenses, and annual household medical expenses of MCCs were ¥292.90 (±1427.80), ¥4804.22 (±11851.63), ¥51064.77 (±52158.76), ¥41933.50 (±39940.02) and ¥11724.94 (±11642.74), respectively. The per capita expenses of 2 weeks' illness, per capita hospitalization expenses, annual household income, annual household cost, and annual household medical expenses of hypertensive co-diabetic patients were more compared to those with other three comorbidity modes.

Conclusion

The prevalence of MCCs was relatively high among middle-aged and older individuals in Yunnan, China, which bought a heavy economic burden. This encourages policy makers and health providers to pay more attention to the behavioral/lifestyle factors, that contribute to multimorbidity to a great extent. Furthermore, health promotion and education in terms of MCCs need to be prioritized in Yunnan.

Multimorbidity transitions and the associated healthcare cost among the Finnish adult population during a two-year follow-up

Background

Ageing of the population increases the prevalence and coexistence of many chronic diseases; a condition called multimorbidity. In Finland, information on the significance of multimorbidity and its relation to the sustainability of healthcare is scarce.

Aim

To assess the prevalence of multimorbidity, the transitions between patient groups with and without multiple diseases and the associated healthcare cost in Finland in 2017-2019.

Methods

A register-based cohort study covering all adults (n = 3,326,467) who used Finnish primary or specialised healthcare services in 2017. At baseline, patients were classified as 'non-multimorbid', 'multimorbid' or 'multimorbid at risk' based on the recordings of a diagnosis of interest. The costs were calculated using the care-related patient grouping and national standard rates. Transition plots were drawn to observe the transition of patients and costs between groups during the two-year follow-up.

Results

At baseline, 62% of patients were non-multimorbid, 23% multimorbid and 15% multimorbid at risk. In two years, the proportion of multimorbid patients increased, especially those at risk. Within the multimorbid at-risk group, total healthcare costs were greatest (€5,027 million), accounting for 62% of the total healthcare cost of the overall patient cohort in 2019. Musculoskeletal diseases, cardiometabolic diseases and tumours were the most common and expensive chronic diseases contributing to the onset of multimorbidity.

Conclusion

Multimorbidity is causing a heavy burden on Finnish healthcare. The estimates of its effect on healthcare usage and costs should be used to guide healthcare planning.

Multimorbidity Patterns and Their Association with Social Determinants, Mental and Physical Health during the COVID-19 Pandemic

BACKGROUND

The challenge posed by multimorbidity makes it necessary to look at new forms of prevention, a fact that has become heightened in the context of the pandemic. We designed a questionnaire to detect multimorbidity patterns in people over 50 and to associate these patterns with mental and physical health, COVID-19, and possible social inequalities.

METHODS

This was an observational study conducted through a telephone interview. The sample size was 1592 individuals with multimorbidity. We use Latent Class Analysis to detect patterns and SF-12 scale to measure mental and physical quality-of-life health. We introduced the two dimensions of health and other social determinants in a multinomial regression model.

RESULTS

We obtained a model with five patterns (entropy = 0.727): 'Relative Healthy', 'Cardiometabolic', 'Musculoskeletal', 'Musculoskeletal and Mental', and 'Complex Multimorbidity'. We found some differences in mental and physical health among patterns and COVID-19 diagnoses, and some social determinants were significant in the multinomial regression.

CONCLUSIONS

We identified that prevention requires the location of certain inequalities associated with the multimorbidity patterns and how physical and mental health have been affected not only by the patterns but also by COVID-19. These findings may be critical in future interventions by health services and governments.

Development and feasibility of an inter-agency physical activity and education programme for adults with multimorbidity in primary care: Activ8

Background

While physical activity is widely recommended for many long-term conditions, it may be difficult to achieve for patients managing multiple conditions. We aimed to determine the feasibility of an inter-agency exercise and education programme for patients with multimorbidity in primary care.

Methods

We conducted an uncontrolled pilot study with adults with multimorbidity, recruited in two community healthcare organisations in an urban area in Ireland. The six-week pilot intervention combined an individually tailored gym-based exercise programme and education to support self-management. Feasibility of the Activ8 programme was assessed using a mixed methods process evaluation. Outcome measures at baseline and at 6 weeks included recruitment and retention, gait speed, grip strength, quality of life and self-efficacy. Focus groups and interviews explored participants and facilitators’ perceptions of the programme.

Results

19 participants with ≥2 chronic conditions were recruited over three-weeks with similar attrition at both sites (≤40%). Overall, the results indicate that Activ8 was feasible and acceptable to patients and practitioners. Quantitative outcome measures suggested improvements in most outcomes. Qualitative data analysis indicated that Activ8 addressed an overarching concept of patient-centeredness among participants. Three key themes included perceived personal programme impact, the personalised composition of the programme and the evolving nature of primary care practice.

Conclusion

While further definitive evidence is needed and attrition from the programme needs to be considered, the Activ8 Programme was acceptable to both patients and professionals in two different primary care areas with the potential for positive impacts for adults living with multimorbidity.

The challenge of managing multimorbid atrial fibrillation: a pan-European European Heart Rhythm Association (EHRA) member survey of current management practices and clinical priorities

As part of the EHRS-PATHS study examining comorbidities in atrial fibrillation (AF) across Europe, the aim was (i) to evaluate how multimorbidity is currently addressed by clinicians during AF treatment to characterize the treatment structure and (ii) to assess how the interdisciplinary management of multimorbid AF is currently conducted. An online survey was distributed among European Heart Rhythm Association (EHRA) members in Europe that included 21 questions and a free-text option for comments on detection, assessment, and management of AF-related comorbidities. A total of 451 responses were received with 339 responses eligible for inclusion. Of these, 221 were male (66%), 300 (91.5%) were physicians, and 196 (57.8%) were working in academic university teaching hospitals. Half of the respondents managed between 20 and 50 patients per month with multimorbid AF. Varying rates of specialist services and referral to these services were available at each location (e.g. heart failure and diabetes), with a greater number of specialist services available at academic university teaching hospitals compared with non-teaching hospitals [e.g. anticoagulation clinic 92 (47%) vs. 50 (35%), P < 0.03]. Barriers to referring to specialist services for AF comorbidities included lack of integrated care model (n = 174, 51%), organizational or institutional issues (n = 145, 43%), and issues with patient adherence (n = 126, 37%), highlighting the need for organizational restructuring and developing an integrated collaborative evidenced-based approach to multimorbid AF care. The survey and analyses of free-text comments demonstrated the need for systematic, integrated management of AF-related comorbidities, and these results will inform the next phases of the EHRA-PATHS study.

Personalised exercise therapy and self-management support for people with multimorbidity: Development of the MOBILIZE intervention

BACKGROUND

To our knowledge, there is no intervention which includes personalised exercise therapy and self-management support for people with multimorbidity, although these interventions may be as effective as for people with single chronic conditions. Therefore, we developed a novel intervention, including personalised exercise therapy and self-management support for people with multimorbidity.

METHODS

We followed the Medical Research Council framework and conducted one scoping review, five systematic reviews, two registry-based studies, one qualitative interview study and a mixed-methods feasibility study. Following an iterative approach, together with feedback from people with multimorbidity and relevant stakeholders, we developed the MOBILIZE intervention.

RESULTS

The intervention included 24 (60 minutes) sessions of personalised exercise therapy and 24 (30 minutes) sessions of self-management support twice a week for 12 weeks, delivered in small groups by specifically trained physiotherapists. The intervention targets physiological, psychosocial, behavioural, and contextual factors to improve health-related quality of life and physical function in people living with multimorbidity.

CONCLUSIONS

We developed a personalised exercise therapy and self-management support programme for people with multimorbidity. The intervention will be tested for its safety and effectiveness in a randomised controlled trial.

Nurse-led Telehealth Intervention for Rehabilitation (Telerehabilitation) Among Community-Dwelling Patients With Chronic Diseases: Systematic Review and Meta-analysis

BACKGROUND

Chronic diseases are putting huge pressure on health care systems. Nurses are widely recognized as one of the competent health care providers who offer comprehensive care to patients during rehabilitation after hospitalization. In recent years, telerehabilitation has opened a new pathway for nurses to manage chronic diseases at a distance; however, it remains unclear which chronic disease patients benefit the most from this innovative delivery mode.

OBJECTIVE

This study aims to summarize current components of community-based, nurse-led telerehabilitation programs using the chronic care model; evaluate the effectiveness of nurse-led telerehabilitation programs compared with traditional face-to-face rehabilitation programs; and compare the effects of telerehabilitation on patients with different chronic diseases.

METHODS

A systematic review and meta-analysis were performed using 6 databases for articles published from 2015 to 2021. Studies comparing the effectiveness of telehealth rehabilitation with face-to-face rehabilitation for people with hypertension, cardiac diseases, chronic respiratory diseases, diabetes, cancer, or stroke were included. Quality of life was the primary outcome. Secondary outcomes included physical indicators, self-care, psychological impacts, and health-resource use. The revised Cochrane risk of bias tool for randomized trials was employed to assess the methodological quality of the included studies. A meta-analysis was conducted using a random-effects model and illustrated with forest plots.

RESULTS

A total of 26 studies were included in the meta-analysis. Telephone follow-ups were the most commonly used telerehabilitation delivery approach. Chronic care model components, such as nurses-patient communication, self-management support, and regular follow-up, were involved in all telerehabilitation programs. Compared with traditional face-to-face rehabilitation groups, statistically significant improvements in quality of life (cardiac diseases: standard mean difference [SMD] 0.45; 95% CI 0.09 to 0.81; P=.01; heterogeneity: X²₁=1.9; I²=48%; P=.16; chronic respiratory diseases: SMD 0.18; 95% CI 0.05 to 0.31; P=.007; heterogeneity: X²₂=1.7; I²=0%; P=.43) and self-care (cardiac diseases: MD 5.49; 95% CI 2.95 to 8.03; P<.001; heterogeneity: X²₅=6.5; I²=23%; P=.26; diabetes: SMD 1.20; 95% CI 0.55 to 1.84; P<.001; heterogeneity: X²₄=46.3; I²=91%; P<.001) were observed in the groups that used telerehabilitation. For patients with any of the 6 targeted chronic diseases, those with hypertension and diabetes experienced significant improvements in their blood pressure (systolic blood pressure: MD 10.48; 95% CI 2.68 to 18.28; P=.008; heterogeneity: X²₁=2.2; I²=54%; P=0.14; diastolic blood pressure: MD 1.52; 95% CI -10.08 to 13.11, P=.80; heterogeneity: X²1=11.5; I²=91%; P<.001), and hemoglobin A1c (MD 0.19; 95% CI -0.19 to 0.57 P=.32; heterogeneity: X²₄=12.4; I²=68%; P=.01) levels. Despite these positive findings, telerehabilitation was found to have no statistically significant effect on improving patients' anxiety level, depression level, or hospital admission rate.

CONCLUSIONS

This review showed that telerehabilitation programs could be beneficial to patients with chronic disease in the community. However, better designed nurse-led telerehabilitation programs are needed, such as those involving the transfer of nurse-patient clinical data. The heterogeneity between studies was moderate to high. Future research could integrate the chronic care model with telerehabilitation to maximize its benefits for community-dwelling patients with chronic diseases.

TRIAL REGISTRATION

International Prospective Register of Systematic Reviews CRD42022324676; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=324676.

Prevalent Multimorbidity Combinations Among Middle-Aged and Older Adults Seen in Community Health Centers

BACKGROUND

Multimorbidity (≥ 2 chronic diseases) is associated with greater disability and higher treatment burden, as well as difficulty coordinating self-management tasks for adults with complex multimorbidity patterns. Comparatively little work has focused on assessing multimorbidity patterns among patients seeking care in community health centers (CHCs).

OBJECTIVE

To identify and characterize prevalent multimorbidity patterns in a multi-state network of CHCs over a 5-year period.

DESIGN

A cohort study of the 2014-2019 ADVANCE multi-state CHC clinical data network. We identified the most prevalent multimorbidity combination patterns and assessed the frequency of patterns throughout a 5-year period as well as the demographic characteristics of patient panels by prevalent patterns.

PARTICIPANTS

The study included data from 838,642 patients aged ≥ 45 years who were seen in 337 CHCs across 22 states between 2014 and 2019.

MAIN MEASURES

Prevalent multimorbidity patterns of somatic, mental health, and mental-somatic combinations of 22 chronic diseases based on the U.S. Department of Health and Human Services Multiple Chronic Conditions framework: anxiety, arthritis, asthma, autism, cancer, cardiac arrhythmia, chronic kidney disease (CKD), chronic obstructive pulmonary disease (COPD), congestive heart failure, coronary artery disease, dementia, depression, diabetes, hepatitis, human immunodeficiency virus (HIV), hyperlipidemia, hypertension, osteoporosis, post-traumatic stress disorder (PTSD), schizophrenia, substance use disorder, and stroke.

KEY RESULTS

Multimorbidity is common among middle-aged and older patients seen in CHCs: 40% have somatic, 6% have mental health, and 24% have mental-somatic multimorbidity patterns. The most frequently occurring pattern across all years is hyperlipidemia-hypertension. The three most frequent patterns are various iterations of hyperlipidemia, hypertension, and diabetes and are consistent in rank of occurrence across all years. CKD-hyperlipidemia-hypertension and anxiety-depression are both more frequent in later study years.

CONCLUSIONS

CHCs are increasingly seeing more complex multimorbidity patterns over time; these most often involve mental health morbidity and advanced cardiometabolic-renal morbidity.

Patterns of the physical, cognitive, and mental health status of older individuals in a real-life primary care setting and differences in coping styles

Background

Physical frailty and cognitive decline are two major consequences of aging and are often in older individuals, especially in those with multimorbidity. These two disorders are known to usually coexist with each other, increasing the risk of each disorder for poor health outcomes. Mental health disorders, anxiety and depression, are common in older people with multimorbidity, in particular those with functional or sensory deficits, and frailty.

Purpose

The aim of this study was to show how physical frailty, cognitive impairments and mental disorders, cluster in the real life setting of older primary care (PC) patients, and how these clusters relate to age, comorbidities, stressful events, and coping strategies. Knowing that, could improve risk stratification of older individuals and guide the action plans.

Methods

Participants were older individuals (≥60, N = 263), attenders of PC, independent of care of others, and not suffering from dementia. For screening participants on physical frailty, cognitive impairment, and mental disorders, we used Fried‘s phenotype model, the Mini-Mental State Examination (MMSE), the Geriatric Anxiety Scale (GAS), and the Geriatric Depression Scale (GDS). For testing participants on coping styles, we used the 14-scale Brief-Coping with Problems Experienced (Brief-COPE) questionnaire. To identify clusters, we used the algorithm fuzzy k-means. To further describe the clusters, we examined differences in age, gender, number of chronic diseases and medications prescribed, some diagnoses of chronic diseases, the number of life events, body mass index, renal function, expressed as the glomerular filtration rate, and coping styles.

Results

The most appropriate cluster solution was the one with three clusters, that were termed as: functional (FUN; N = 139), with predominant frailty or dysfunctional (DFUN; N = 81), and with predominant cognitive impairments or cognitively impaired (COG-IMP; N = 43). Participants in two pathologic clusters, DFUN and COG-IMP, were in average older and had more somatic diseases, compared to participants in cluster FUN. Significant differences between the clusters were found in diagnoses of osteoporosis, osteoarthritis, anxiety/depression, cerebrovascular disease, and periphery artery disease. Participants in cluster FUN expressed mostly positive reframing coping style. Participants in two pathological clusters were represented with negative coping strategies. Religion and self-blame were coping mechanisms specific only for cluster DFUN; self-distraction only for cluster COG-IMP; and these two latter clusters shared the mechanisms of behavioral disengagement and denial.

Conclusion

The research approach presented in this study may help PC providers in risk stratification of older individuals and in getting insights into behavioral and coping strategies of patients with similar comorbidity patterns and functional disorders, which may guide them in preparing prevention and care plans. By providing some insights into the common mechanisms and pathways of clustering frailty, cognitive impairments and mental disorders, this research approach is useful for creating new hypotheses and in accelerating geriatric research.

Effect of social prescribing link workers on health outcomes and costs for adults in primary care and community settings: a systematic review

OBJECTIVES

To establish the evidence base for the effects on health outcomes and costs of social prescribing link workers (non-health or social care professionals who connect people to community resources) for people in community settings focusing on people experiencing multimorbidity and social deprivation.

DESIGN

Systematic review and narrative synthesis using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach.

DATA SOURCES

Cochrane Database, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, EU Clinical Trials Register, CINAHL, Embase, Global Health, PubMed/MEDLINE, PsycInfo, LILACS, Web of Science and grey literature were searched up to 31 July 2021. A forward citation search was completed on 9 June 2022.

ELIGIBILITY CRITERIA

Controlled trials meeting the Cochrane Effectiveness of Practice and Organisation of Care (EPOC) guidance on eligible study designs assessing the effect of social prescribing link workers for adults in community settings on any outcomes. No language restrictions were applied.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted data, evaluated study quality using the Cochrane EPOC risk of bias tool and judged certainty of the evidence. Results were synthesised narratively.

RESULTS

Eight studies (n=6500 participants), with five randomised controlled trials at low risk of bias and three controlled before-after studies at high risk of bias, were included. Four included participants experiencing multimorbidity and social deprivation. Four (n=2186) reported no impact on health-related quality of life (HRQoL). Four (n=1924) reported mental health outcomes with three reporting no impact. Two US studies found improved ratings of high-quality care and reduced hospitalisations for people with multimorbidity experiencing deprivation. No cost-effectiveness analyses were identified. The certainty of the evidence was low or very low.

CONCLUSIONS

There is an absence of evidence for social prescribing link workers. Policymakers should note this and support evaluation of current programmes before mainstreaming.

PROSPERO REGISTRATION NUMBER

CRD42019134737.

Association of Multimorbidity and Excess Mortality After Fractures Among Danish Adults

IMPORTANCE

Limited knowledge about interactions among health disorders impedes optimal patient care. Because comorbidities are common among patients 50 years and older with fractures, these fractures provide a useful setting for studying interactions among disorders.

OBJECTIVE

To define multimorbidity clusters at the time of fracture and quantify the interaction between multimorbidity and fracture in association with postfracture excess mortality.

DESIGN, SETTING, AND PARTICIPANTS

This nationwide cohort study included 307 870 adults in Denmark born on or before January 1, 1951, who had an incident low-trauma fracture between January 1, 2001, and December 31, 2014, and were followed up through December 31, 2016. Data were analyzed from February 1 to March 31, 2022.

MAIN OUTCOMES AND MEASURES

Fracture and 32 predefined chronic diseases recorded within 5 years before the index fracture were identified from the Danish National Hospital Discharge Register. Death was ascertained from the Danish Register on Causes of Death. Latent class analysis was conducted to identify multimorbidity clusters. Relative survival analysis was used to quantify excess mortality associated with the combination of multimorbidity and fractures at specific sites.

RESULTS

Among the 307 870 participants identified with incident fractures, 95 372 were men (31.0%; mean [SD] age at fracture, 72.3 [11.2] years) and 212 498 were women (69.0%; mean [SD] age at fracture, 74.9 [11.2] years). During a median of 6.5 (IQR, 3.0-11.0) years of follow-up, 41 017 men (43.0%) and 81 727 women (38.5%) died. Almost half of patients with fractures (42.9%) had at least 2 comorbidities. Comorbidities at fracture were categorized as low-multimorbidity (60.5% in men and 66.5% in women), cardiovascular (23.7% in men and 23.5% in women), diabetic (5.6% in men and 5.0% in women), malignant (5.1% in men and 5.0% in women), and mixed hepatic and/or inflammatory (5.1% in men only) clusters. These clusters distinguished individuals with advanced, complex, or late-stage disease from those with earlier-stage disease. Multimorbidity and proximal or lower leg fractures were associated with increased mortality risk, with the highest excess mortality found in patients with hip fracture in the malignant cluster (1-year excess mortality: 40.8% [95% CI: 38.1%-43.6%]). The combination of multimorbidity and fracture compounded the association with mortality, conferring much greater risk than either alone.

CONCLUSIONS AND RELEVANCE

Concomitant illnesses were common and clustered into distinct multimorbidity clusters that were associated with excess postfracture mortality. The compound contribution of multimorbidity to postfracture excess mortality highlights the need for more comprehensive approaches in these high-risk patients. The analytical approach applied to fracture could also be used to examine other sentinel health events.

Prescribing cascades in community-dwelling adults: A systematic review

The misattribution of an adverse drug reaction (ADR) as a symptom or illness can lead to the prescribing of additional medication, referred to as a prescribing cascade. The aim of this systematic review is to identify published prescribing cascades in community-dwelling adults. A systematic review was reported in line with the PRISMA guidelines and pre-registered with PROSPERO. Electronic databases (Medline [Ovid], EMBASE, PsycINFO, CINAHL, Cochrane Library) and grey literature sources were searched. Inclusion criteria: community-dwelling adults; risk-prescription medication; outcomes-initiation of new medicine to "treat" or reduce ADR risk; study type-cohort, cross-sectional, case-control, and case-series studies. Title/abstract screening, full-text screening, data extraction, and methodological quality assessment were conducted independently in duplicate. A narrative synthesis was conducted. A total of 101 studies (reported in 103 publications) were included. Study sample sizes ranged from 126 to 11 593 989 participants and 15 studies examined older adults specifically (≥60 years). Seventy-eight of 101 studies reported a potential prescribing cascade including calcium channel blockers to loop diuretic (n = 5), amiodarone to levothyroxine (n = 5), inhaled corticosteroid to topical antifungal (n = 4), antipsychotic to anti-Parkinson drug (n = 4), and acetylcholinesterase inhibitor to urinary incontinence drugs (n = 4). Identified prescribing cascades occurred within three months to one year following initial medication. Methodological quality varied across included studies. Prescribing cascades occur for a broad range of medications. ADRs should be included in the differential diagnosis for patients presenting with new symptoms, particularly older adults and those who started a new medication in the preceding 12 months.

Investigating households' out-of-pocket healthcare expenditures based on number of chronic conditions in Riyadh, Saudi Arabia: a cross-sectional study using quantile regression approach

OBJECTIVES

This study investigated the level and associated factors, focusing on the number of individuals with chronic conditions, of out-of-pocket healthcare expenditures (OOPHE).

DESIGN

A cross-sectional study was conducted from January 2021 to June 2021.

SETTING

Riyadh Province, Saudi Arabia.

PARTICIPANTS

A total of 1176 households that used any healthcare services at least once in the past 3 months.

OUTCOME MEASURES

The OOPHE incurred in the previous 3-month period when a household member is receiving health services. The effects of predisposing, enabling and need factors on the level of OOPHE. The association between the number of individuals with chronic conditions in a household and OOPHE along with the OOPHE distribution.

RESULTS

The average household OOPHE among all the surveyed households (n=1176) was SAR1775.30. For households affected by one chronic condition, OOPHE was SAR1806, and for households affected by more than one chronic condition, OOPHE was SAR2704. If the head of the household was older, better educated and employed, they were more vulnerable to a higher OOPHE (p<0.0001). At the household level, the increased number of family members with chronic conditions, the presence of a member less than 14 years old, higher socioeconomic status, coverage from health insurance plans, residence in an urban area and the presence of a member with a disability in the household were correlated with a considerably greater level of OOPHE (p<0.0001). The result of quantile regression analysis indicates that an increase in the number of members with chronic conditions in a household was significantly associated with greater overall OOPHE at higher health expenditure quantiles.

CONCLUSIONS

The burden of OOPHE on households with chronic conditions remains heavy, and some disparities still exist. The number of individuals with chronic conditions in a household plays a substantial and prominent role in increasing the risk of incurring OOPHE.

Actions taken to safeguard the intended health care chain of older people with multiple diagnoses - a critical incident study

Background

Older people with multiple diagnoses often have problems coping with their daily lives at home because of lack of coordination between various parts of the healthcare chain during the transit from hospital care to the home. To provide good care to those persons who have the most complex needs, regions and municipalities must work together. It is of importance to develop further empirical knowledge in relation to older persons with multiple diagnoses to illuminate possible obstacles to person-centred care during the transition between healthcare institutions and the persons livelihood. The aim of the present study was to describe nurses’ experienced critical incidents in different parts of the intended healthcare chain of older people with multiple diagnoses.

Methods

The sample consisted of 18 RNs in different parts of the healthcare system involved in the care of older people with multiple diagnoses. Data were collected by semi structured interviews and analysed according to Critical Incident Technique (CIT). A total of 169 critical incidents were identified describing experiences in recently experienced situations.

Results

The result showed that organizational restrictions in providing care and limitations in collaboration were the main areas of experienced critical incidents. Actions took place due to the lack of preventive actions for care, difficulties in upholding patients’ legal rights to participation in care, deficiencies in cooperation between organizations as well as ambiguous responsibilities and roles. The RNs experienced critical incidents that required moral actions to ensure continued person-centred nursing and provide evidence-based care. Both types of critical incidents required sole responsibility from the nurse. The RNs acted due to ethics, ‘walking the extra mile’, searching for person-centred information, and finding out own knowledge barriers.

Conclusions

In conclusion and based on this critical incident study, home-based healthcare of older people with multiple diagnoses requires a nurse that is prepared to take personal and moral responsibility to ensure person-centred home-based healthcare. Furthermore, the development of in-between adjustments of organizations to secure cooperation, and transference of person-centred knowledge is needed.

Community prevalence and dyad disease pattern of multimorbidity in China and India: a systematic review

BACKGROUND

Driven by the increasing life expectancy, China and India, the two most populous countries in the world are experiencing a rising burden of multimorbidity. This study aims to explore community prevalence and dyad patterns of multimorbidity in China and India.

METHODS

We conducted a systematic review of five English and Chinese electronic databases. Studies involving adults 18 years or older at a community level, which reported multimorbidity prevalence and/or patterns were included. A modified Newcastle-Ottawa Scale was used for quality assessment. Despite large heterogeneity among reported studies, a systematic synthesis of the results was conducted to report the findings.

RESULTS

From 13 996 studies retrieved, 59 studies met the inclusion criteria (46 in China, 9 in India and 4 in both). The median prevalence of multimorbidity was 30.7% (IQR 17.1, 49.4), ranging from 1.5% to 90.5%. There was a large difference in multimorbidity prevalence between China and India, with median prevalence being 36.1% (IQR 19.6, 48.8) and 28.3% (IQR 8.9, 56.8), respectively. Among 27 studies that reported age-specific prevalence, 19 studies found multimorbidity prevalence increased with age, while 8 studies observed a paradoxical reduction in the oldest age group. Of the 34 studies that reported sex-specific prevalence, 86% (n=32) observed a higher prevalence in females. The most common multimorbidity patterns from 14 studies included hypertensive diseases combined with diabetes mellitus, arthropathies, heart diseases and metabolic disorders. All included studies were rated as fair or poor quality.

CONCLUSION

Multimorbidity is highly prevalent in China and India with hypertensive diseases and other comorbidities being the most observed patterns. The overall quality of the studies was low and there was a lack of representative samples in most studies. Large epidemiology studies, using a common definition of multimorbidity and national representative samples, with sex disaggregation are needed in both countries.

PROSPERO REGISTRATION NUMBER

CRD42020176774.

Multimorbidity patterns and the relation to self-rated health among older Japanese people: a nationwide cross-sectional study

OBJECTIVES

Classifying individuals into multimorbidity patterns can be useful to identify the target population with poorer clinical outcomes. Self-rated health (SRH) is one of the core outcomes in multimorbidity patients. Although studies have reported that multimorbidity is associated with poor SRH, whether certain patterns have stronger associations remains unknown. Therefore, this study aimed to identify the prevalence and patterns of multimorbidity and investigate the association between multimorbidity patterns and SRH in an older Japanese population.

DESIGN

Cross-sectional study.

SETTING

Data were obtained from the 2013 Comprehensive Survey of Living Conditions, a nationally representative survey of the general Japanese population.

PARTICIPANTS

This study mainly examined 23 730 participants aged ≥65 years who were not hospitalised or institutionalised.

PRIMARY OUTCOME MEASURE

Poor SRH was defined as choosing 'not very good' or 'bad' from five options: 'excellent', 'fairly good', 'average', 'not very good' and 'bad'.

RESULTS

The prevalence of multimorbidity was 40.9% and that of poor SRH was 23.8%. Three multimorbidity patterns were identified by exploratory factor analysis: (1) degenerative/mental health, (3) malignant/digestive/urological/haematological and (3) cardiovascular/metabolic. Multivariable modified Poisson regression analysis revealed that high malignant/digestive/urological/haematological, degenerative/mental health and cardiovascular/metabolic pattern scores, corresponding to the number of affected body systems in each pattern, were significantly associated with poor SRH (adjusted risk ratio (aRR)=1.68, 95% CI: 1.60 to 1.76; aRR=1.63, 95% CI: 1.58 to 1.69; and aRR=1.31, 95% CI: 1.26 to 1.36, respectively). When including the Kessler 6 score, a screening scale for psychological distress, in the analysis, the association between each multimorbidity pattern score and poor SRH decreased.

CONCLUSIONS

Malignant/digestive/urological/haematological and degenerative/mental health patterns may be associated with a high risk for poor SRH. Further research should focus on interventions to improve SRH in multimorbidity patients.

Optimising a person-centred approach to stopping medicines in older people with multimorbidity and polypharmacy using the DExTruS framework: a realist review

BACKGROUND

Tackling problematic polypharmacy requires tailoring the use of medicines to individual circumstances and may involve the process of deprescribing. Deprescribing can cause anxiety and concern for clinicians and patients. Tailoring medication decisions often entails beyond protocol decision-making, a complex process involving emotional and cognitive work for healthcare professionals and patients. We undertook realist review to highlight and understand the interactions between different factors involved in deprescribing and to develop a final programme theory that identifies and explains components of good practice that support a person-centred approach to deprescribing in older patients with multimorbidity and polypharmacy.

METHODS

The realist approach involves identifying underlying causal mechanisms and exploring how, and under what conditions they work. We conducted a search of electronic databases which were supplemented by citation checking and consultation with stakeholders to identify other key documents. The review followed the key steps outlined by Pawson et al. and followed the RAMESES standards for realist syntheses.

RESULTS

We included 119 included documents from which data were extracted to produce context-mechanism-outcome configurations (CMOCs) and a final programme theory. Our programme theory recognises that deprescribing is a complex intervention influenced by a multitude of factors. The components of our final programme theory include the following: a supportive infrastructure that provides clear guidance around professional responsibilities and that enables multidisciplinary working and continuity of care, consistent access to high-quality relevant patient contextual data, the need to support the creation of a shared explanation and understanding of the meaning and purpose of medicines and a trial and learn approach that provides space for monitoring and continuity. These components may support the development of trust which may be key to managing the uncertainty and in turn optimise outcomes. These components are summarised in the novel DExTruS framework.

CONCLUSION

Our findings recognise the complex interpretive practice and decision-making involved in medication management and identify key components needed to support best practice. Our findings have implications for how we design medication review consultations, professional training and for patient records/data management. Our review also highlights the role that trust plays both as a central element of tailored prescribing and a potential outcome of good practice in this area.

Predictors of Dropout in a Digital Intervention for the Prevention and Treatment of Depression in Patients With Chronic Back Pain: Secondary Analysis of Two Randomized Controlled Trials

Background

Depression is a common comorbid condition in individuals with chronic back pain (CBP), leading to poorer treatment outcomes and increased medical complications. Digital interventions have demonstrated efficacy in the prevention and treatment of depression; however, high dropout rates are a major challenge, particularly in clinical settings.

Objective

This study aims to identify the predictors of dropout in a digital intervention for the treatment and prevention of depression in patients with comorbid CBP. We assessed which participant characteristics may be associated with dropout and whether intervention usage data could help improve the identification of individuals at risk of dropout early on in treatment.

Methods

Data were collected from 2 large-scale randomized controlled trials in which 253 patients with a diagnosis of CBP and major depressive disorder or subclinical depressive symptoms received a digital intervention for depression. In the first analysis, participants’ baseline characteristics were examined as potential predictors of dropout. In the second analysis, we assessed the extent to which dropout could be predicted from a combination of participants’ baseline characteristics and intervention usage variables following the completion of the first module. Dropout was defined as completing <6 modules. Analyses were conducted using logistic regression.

Results

From participants’ baseline characteristics, lower level of education (odds ratio [OR] 3.33, 95% CI 1.51-7.32) and both lower and higher age (a quadratic effect; age: OR 0.62, 95% CI 0.47-0.82, and age²: OR 1.55, 95% CI 1.18-2.04) were significantly associated with a higher risk of dropout. In the analysis that aimed to predict dropout following completion of the first module, lower and higher age (age: OR 0.60, 95% CI 0.42-0.85; age²: OR 1.59, 95% CI 1.13-2.23), medium versus high social support (OR 3.03, 95% CI 1.25-7.33), and a higher number of days to module completion (OR 1.05, 95% CI 1.02-1.08) predicted a higher risk of dropout, whereas a self-reported negative event in the previous week was associated with a lower risk of dropout (OR 0.24, 95% CI 0.08-0.69). A model that combined baseline characteristics and intervention usage data generated the most accurate predictions (area under the receiver operating curve [AUC]=0.72) and was significantly more accurate than models based on baseline characteristics only (AUC=0.70) or intervention usage data only (AUC=0.61). We found no significant influence of pain, disability, or depression severity on dropout.

Conclusions

Dropout can be predicted by participant baseline variables, and the inclusion of intervention usage variables may improve the prediction of dropout early on in treatment. Being able to identify individuals at high risk of dropout from digital health interventions could provide intervention developers and supporting clinicians with the ability to intervene early and prevent dropout from occurring.

Experiences of patients with multimorbidity with primary care and the association with patient activation: a cross-sectional study in Germany

OBJECTIVES

This study aimed to explore the association between patient activation and patients' experience of care among an elderly multimorbid population in Germany.

DESIGN

Cross-sectional study.

SETTING

Primary care practices in two German settings.

PARTICIPANTS

346 patients with 3 or more chronic conditions aged 65 years and over from 36 primary care practices.

OUTCOME MEASURES

Patient activation was measured with the patient activation measure (PAM). To assess patient experiences with primary care, a set of questions concerning domains of primary care were included. Multilevel regression analyses were performed to examine which domains of care were associated with patient activation.

RESULTS

Out of 1243 invited patients, a total of 346 took part in the study (participation rate 27.8 %). Mean PAM score was 76.1. Across all patients, 3.8% achieved PAM level 1, 7.5% level 2, 27.2% level 3% and 60.7% level 4. PAM scores suggest a highly activated patient group. In the regression analysis, three out ten domains of patients' experiences showed an association with patient activation. The domains 'being involved in decision as much as desired' (B=-8.56, p=0.012) and 'receiving a self-management plan' (B=6.51, p=0.051) were associated with higher patient activation scores. Patients with an up-to-date medication plan had lower patient activation scores (B=-12.01, p=0.041).

CONCLUSION

Specific domains of primary care were found to be associated with patient activation. To enhance patient activation, primary care physicians may increase involvement of patients in decisions. Future research should examine the causality of these associations.

TRIAL REGISTRATION NUMBER

DRKS00015718.

Households' Direct Economic Burden Associated with Chronic Non-Communicable Diseases in Saudi Arabia

Households' economic burden associated with chronic non-communicable diseases (NCDs) is a deterrent to healthcare access, adversely impacting patients' health. Therefore, we investigated the extent of out-of-pocket (OOP) spending among individuals diagnosed with chronic NCDs among household members in Riyadh, Saudi Arabia. Face-to-face interviews were conducted among households in Riyadh Province from the beginning of January 2021 to the end of June 2021. The respondents were asked to record OOP spending throughout the past three months in their health. A generalized linear regression model was used to determine the effects of several factors on the level of OOP spending. A total of 39.6% of the households studied had at least one member with a chronic NCD. Diabetes patients spent an average of SAR 932 (USD 248), hypertension patients SAR 606 (USD 162), and hypothyroid patients SAR 402 (USD 107). It was shown that households with older and more educated members had greater OOP spending. Households with an employed head of household, more family members, higher SES status, health insurance coverage, and urban residency had significantly higher OOP expenditure. The burden of OOP spending for chronic NCD households remains high, with some disparities. The research offers important information for decision making to lower OOP cost among NCD households.

Multimorbidity and Complex Multimorbidity in India: Findings from the 2017-2018 Longitudinal Ageing Study in India (LASI)

Complex multimorbidity refers to the co-occurrence of three or more chronic illnesses across >2 body systems, which may identify persons in need of additional medical support and treatment. There is a scarcity of evidence on the differences in patient outcomes between non-complex (≥2 conditions) and complex multimorbidity groups. We evaluated the prevalence and patient outcomes of complex multimorbidity and compared them to non-complex multimorbidity. We included 30,489 multimorbid individuals aged ≥45 years from the Longitudinal Ageing Study in India (LASI) from wave-1 conducted in 2017−2018. We employed a log link in generalised linear models (GLM) to identify possible risk factors presenting the adjusted prevalence−risk ratio (APRR) and adjusted prevalence−risk difference (APRD) with 95% confidence interval. The prevalence of complex multimorbidity was 34.5% among multimorbid individuals. Participants residing in urban areas [APRR: 1.10 (1.02, 1.20)], [APRD: 0.04 (0.006, 0.07)] were more likely to report complex multimorbidity. Participants with complex multimorbidity availed significantly higher inpatient department services and had higher expenditure as compared to the non-complex multimorbidity group. Our findings have major implications for healthcare systems in terms of meeting the requirements of people with complicated multimorbidity, as they have significantly higher inpatient health service utilisation, higher medical costs, and poorer self-rated health.

Contexts and mechanisms relevant to General Practitioner (GP) based interventions to reduce adverse drug events (ADE) in community dwelling older adults: a rapid realist review

Background: Older adults in Ireland are at increased risk of adverse drug events (ADE) due, in part, to increasing rates of polypharmacy. Interventions to reduce ADE in community dwelling older adults (CDOA) have had limited success, therefore, new approaches are required. A realist review uses a different lens to examine why and how interventions were supposed to work rather than if, they worked. A rapid realist review (RRR) is a more focused and accelerated version. The aim of this RRR is to identify and examine the contexts and mechanisms that play a role in the outcomes relevant to reducing ADE in CDOA in the GP setting that could inform the development of interventions in Ireland. Methods: Six candidate theories (CT) were developed, based on knowledge of the field and recent literature, in relation to how interventions are expected to work. These formed the search strategy. Eighty full texts from 633 abstracts were reviewed, of which 27 were included. Snowballing added a further five articles, relevant policy documents increased the total number to 45. Data were extracted relevant to the theories under iteratively developed sub-themes using NVivo software. Results: Of the six theories, three theories, relating to GP engagement in interventions, relevance of health policy documents for older adults, and shared decision-making, provided data to guide future interventions to reduce ADEs for CDOA in an Irish setting. There was insufficient data for two theories, a third was rejected as existing barriers in the Irish setting made it impractical to use. Conclusions: To improve the success of Irish GP based interventions to reduce ADEs for CDOA, interventions must be relevant and easily applied in practice, supported by national policy and be adequately resourced. Future research is required to test our theories within a newly developed intervention.

Multimorbidity and Mental Health Trajectories Among Middle-Aged and Older U.S. Adults During the COVID-19 Pandemic: Longitudinal Findings From the COVID-19 Coping Study

Background and Objectives

This study aimed to examine the associations between multimorbidity at the COVID-19 pandemic onset and subsequent longitudinal trajectories of depressive symptoms, anxiety symptoms, and loneliness in middle-aged and older adults over a 12-month follow-up.

Research Design and Methods

Data were from monthly online questionnaires in the COVID-19 Coping Study of U.S. adults aged ≥55 from April/May 2020 through April/May 2021 (N = 4,024). Multimorbidity was defined as having ≥2 versus <2 chronic conditions at baseline. Mental health outcomes were assessed monthly as depressive symptoms (8-item Center for Epidemiologic Studies Depression scale), anxiety symptoms (5-item Beck Anxiety Inventory), and loneliness (3-item UCLA Loneliness Scale). We used multivariable-adjusted population- and attrition-weighted mixed-effects linear models to examine the longitudinal associations between multimorbidity and mental health symptoms.

Results

Multimorbidity at the pandemic onset was associated with elevated depressive (b = 0.37; 95% CI: 0.16–0.59) and anxiety (b = 0.39; 95% CI: 0.15–0.62) symptoms at baseline. Changes in symptoms for all three mental health outcomes were nonlinear over time, with worsening symptoms over the first 6 months of the pandemic (April/May to September/October 2020), followed by improvement in symptoms over the subsequent 6 months (September/October 2020 to April/May 2021). Middle-aged and older adults with multimorbidity experienced faster rates of change in anxiety symptoms and loneliness than those without multimorbidity, with persistently elevated mental health symptomatology throughout the follow-up.

Discussion and Implications

Results highlight the unique and persistent mental health risks experienced by middle-aged and older adults with multimorbidity during the COVID-19 pandemic. The observed improvements in symptoms underscore the mental resilience of these individuals, indicating their adaptation to the ongoing pandemic.

Patient activation for self‐management among adult patients with multimorbidity in primary healthcare settings

Background and Aims

Methods

Results

Conclusion

Deprescribing medicines in older people living with multimorbidity and polypharmacy: the TAILOR evidence synthesis

BACKGROUND

Tackling problematic polypharmacy requires tailoring the use of medicines to individual needs and circumstances. This may involve stopping medicines (deprescribing) but patients and clinicians report uncertainty on how best to do this. The TAILOR medication synthesis sought to help understand how best to support deprescribing in older people living with multimorbidity and polypharmacy.

OBJECTIVES

We identified two research questions: (1) what evidence exists to support the safe, effective and acceptable stopping of medication in this patient group, and (2) how, for whom and in what contexts can safe and effective tailoring of clinical decisions related to medication use work to produce desired outcomes? We thus described three objectives: (1) to undertake a robust scoping review of the literature on stopping medicines in this group to describe what is being done, where and for what effect; (2) to undertake a realist synthesis review to construct a programme theory that describes 'best practice' and helps explain the heterogeneity of deprescribing approaches; and (3) to translate findings into resources to support tailored prescribing in clinical practice.

DATA SOURCES

Experienced information specialists conducted comprehensive searches in MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Web of Science, EMBASE, The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials), Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports, Google (Google Inc., Mountain View, CA, USA) and Google Scholar (targeted searches).

REVIEW METHODS

The scoping review followed the five steps described by the Joanna Briggs Institute methodology for conducting a scoping review. The realist review followed the methodological and publication standards for realist reviews described by the Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) group. Patient and public involvement partners ensured that our analysis retained a patient-centred focus.

RESULTS

Our scoping review identified 9528 abstracts: 8847 were removed at screening and 662 were removed at full-text review. This left 20 studies (published between 2009 and 2020) that examined the effectiveness, safety and acceptability of deprescribing in adults (aged ≥ 50 years) with polypharmacy (five or more prescribed medications) and multimorbidity (two or more conditions). Our analysis revealed that deprescribing under research conditions mapped well to expert guidance on the steps needed for good clinical practice. Our findings offer evidence-informed support to clinicians regarding the safety, clinician acceptability and potential effectiveness of clinical decision-making that demonstrates a structured approach to deprescribing decisions. Our realist review identified 2602 studies with 119 included in the final analysis. The analysis outlined 34 context-mechanism-outcome configurations describing the knowledge work of tailored prescribing under eight headings related to organisational, health-care professional and patient factors, and interventions to improve deprescribing. We conclude that robust tailored deprescribing requires attention to providing an enabling infrastructure, access to data, tailored explanations and trust.

LIMITATIONS

Strict application of our definition of multimorbidity during the scoping review may have had an impact on the relevance of the review to clinical practice. The realist review was limited by the data (evidence) available.

CONCLUSIONS

Our combined reviews recognise deprescribing as a complex intervention and provide support for the safety of structured approaches to deprescribing, but also highlight the need to integrate patient-centred and contextual factors into best practice models.

FUTURE WORK

The TAILOR study has informed new funded research tackling deprescribing in sleep management, and professional education. Further research is being developed to implement tailored prescribing into routine primary care practice.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42018107544 and PROSPERO CRD42018104176.

FUNDING

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 32. See the NIHR Journals Library website for further project information.

Advancing multimorbidity management in primary care: a narrative review

BACKGROUND

Multimorbidity, defined as the coexistence of two or more chronic conditions in the same individual, is becoming a crucial health issue in primary care. Patients with multimorbidity utilize health care at a higher rate and have higher mortality rates and poorer quality of life compared to patients with single diseases.

AIMS

To explore evidence on how to advance multimorbidity management, with a focus on primary care. Primary care is where a large number of patients with multimorbidity are managed and is considered to be a gatekeeper in many health systems.

METHODS

A narrative review was conducted using four major electronic databases consisting of PubMed, Cochrane, World Health Organization database, and Google scholar. In the first round of reviews, priority was given to review papers summarizing the current issues and challenges in the management of multimorbidity. Thematic analysis using an inductive approach was used to build a framework on how to advance management. The second round of review focused on original articles providing evidence within the primary care context.

RESULTS

The review found that advancing multimorbidity management in primary care requires a health system approach and a patient-centered approach. The health systems approach includes three major areas: (i) improves access to care, (ii) promotes generalism, and (iii) provides a decision support system. For the patient-centered approach, four key aspects are essential for multimorbidity management: (i) promoting doctor-patient relationship, (ii) prioritizing health problems and sharing decision-making, (iii) supporting self-management, and (iv) integrating care.Advancement of multimorbidity management in primary care requires integrating concepts of multimorbidity management guidelines with concepts of patient-centered and chronic care models. This simple integration provides an overarching framework for advancing the health care system, connecting the processes of individualized care plans, and integrating care with other providers, family members, and the community.

Multimorbidity patterns in adult day health center clients with dementia: a latent class analysis

Background

Persons living with dementia (PLWD) in adult day centers (ADCs) represent a complex and vulnerable population whose well-being is at risk based on numerous factors. Greater knowledge of the interaction between dementia, chronic conditions, and social determinants of health would enable ADCs to identify and target the use of their resources to better support clients in need of in-depth intervention. The purpose of this paper is to (a) classify PLWD in ADCs according to their level of medical complexity and (b) identify the demographic, functional, and clinical characteristics of those with the highest degree of medical complexity.

Methods

This was a secondary data analysis of 3052 clients with a dementia diagnosis from 53 ADCs across the state of California between 2012 and 2019. The most common diagnosis codes were organized into 28 disease categories to enable a latent class analysis (LCA). Chi-square test, analysis of variance (ANOVA), and Kruskal-Wallis tests were conducted to examine differences among latent classes with respect to clinical and functional characteristics.

Results

An optimal 4-class solution was chosen to reflect chronic conditions among PLWD: high medical complexity, moderate medical complexity, low medical complexity, and no medical complexity. Those in the high medical complexity were taking an average of 12.72 (+/− 6.52) medications and attending the ADC an average of 3.98 days (+/− 1.31) per week—values that exceeded any other class. They also experienced hospitalizations more than any other group (19.0%) and met requirements for the nursing facility level of care (77.4%). In addition, the group experienced the greatest frequency of bladder (57.5%) and bowel (15.7%) incontinence.

Conclusions

Our results illustrate a high degree of medical complexity among PLWD in ADCs. A majority of PLWD not only have multimorbidity but are socially disadvantaged. Our results demonstrate that a comprehensive multidisciplinary approach that involves community partners such as ADCs is critically needed that addresses functional decline, loneliness, social isolation, and multimorbidity which can negatively impact PLWD.

Multimorbidity patterns across race/ethnicity as stratified by age and obesity

The objective of our study is to assess differences in prevalence of multimorbidity by race/ethnicity. We applied the FP-growth algorithm on middle-aged and elderly cohorts stratified by race/ethnicity, age, and obesity level. We used 2016–2017 data from the Cerner HealthFacts electronic health record data warehouse. We identified disease combinations that are shared by all races/ethnicities, those shared by some, and those that are unique to one group for each age/obesity level. Our findings demonstrate that even after stratifying by age and obesity, there are differences in multimorbidity prevalence across races/ethnicities. There are multimorbidity combinations distinct to some racial groups—many of which are understudied. Some multimorbidities are shared by some but not all races/ethnicities. African Americans presented with the most distinct multimorbidities at an earlier age. The identification of prevalent multimorbidity combinations amongst subpopulations provides information specific to their unique clinical needs.