Prevalence of multimorbidity in a geographically defined American population: patterns by age, sex, and race/ethnicity

Prevalence of Combined Somatic and Mental Health Multimorbidity: Patterns by Age, Sex, and Race/Ethnicity

BACKGROUND

The coexistence of chronic mental health conditions with somatic conditions (somatic-mental multimorbidity, or SMM) is common and has been associated with greater symptom burden and functional impairment, higher costs, and excess mortality. However, most existing literature focused on the co-occurrence of an index mental health condition with specific additional conditions. By contrast, we studied the prevalence and patterns of SMM more broadly considering 19 selected conditions, and we focused on differences by age, sex, and race/ethnicity.

METHODS

The Rochester Epidemiology Project (REP) records-linkage system was used to identify all residents of Olmsted County, MN, on April 1, 2010. We identified individuals with each of 19 common chronic conditions, including 5 mental health conditions, using the International Classification of Diseases, ninth revision (ICD-9) codes received from any health care provider between April 1, 2005 and March 31, 2010.

RESULTS

Among the 138,858 residents of the county, 52.4% were women, and 7.9% had SMM. SMM increased steeply with older age, was 1.7 times more common in women, and was lower in Asians compared with whites. Of the 10,903 persons with SMM, 7,739 (71.0%) were younger than 65 years. Depressive and anxiety disorders were the most common conditions involved in SMM. The dyads that were observed more frequently or less frequently than expected by chance varied in composition by age and sex.

CONCLUSIONS

SMM that reaches medical attention is highly prevalent across all age groups, is more frequent in women, is less frequent in Asians, and encompasses a wide range of conditions.

Multimorbidity and access to major cancer surgery at high-volume hospitals in a regionalized era

BACKGROUND

The Institute of Medicine has recently prioritized access of quality cancer care to vulnerable persons including multimorbid patients. Despite promotional efforts to regionalize major surgical procedures to high-volume hospitals (HVHs), little is known about change in access to HVH over time among multimorbid patients in need of major cancer surgery. We performed a time-trend appraisal of access of multimorbid persons to HVH for major cancer surgery within a large nationally representative cohort.

METHODS

We identified 168,934 patients who underwent 6 major cancer surgeries from the Nationwide Inpatient Sample (1998 to 2010). Comorbidities were identified using Elixhauser's method. HVHs were defined as hospitals of highest procedure volumes that treated 1/3 of all the patients. Logistic regression models and predictive margins were used to assess the adjusted effects of comorbidity on receiving major cancer surgeries at HVH.

RESULTS

Of all, 45.7% of the patients had 2 comorbidities or more. Multimorbidity predicted decreased access to HVH for esophagectomy, total gastrectomy, pancreatectomy, hepatectomy, and proctectomy, but not for distal gastrectomy, after controlling for covariates. A comorbidity level by year interaction analysis also showed that little disparity existed for receiving distal gastrectomy at an HVH, whereas the predicted difference in probability of receiving any of the other 5 major cancer procedures remained prominent between the years 1998 and 2010.

CONCLUSIONS

In this large 12-year time-trend study, multimorbid cancer patients have sustained low access to HVH for major cancer surgery across many oncologic resections. These results continue to reinforce and highlight the need for policy targeted research and intervention aimed at improving these access gaps.

Multiple Chronic Conditions in Older Adults with Acute Coronary Syndromes

Older adults presenting with acute coronary syndromes (ACSs) often have multiple chronic conditions (MCCs). In addition to traditional cardiovascular (CV) risk factors (ie, hypertension, hyperlipidemia, and diabetes), common CV comorbidities include heart failure, stroke, and atrial fibrillation, whereas prevalent non-CV comorbidities include chronic kidney disease, anemia, depression, and chronic obstructive pulmonary disease. The presence of MCCs affects the presentation (eg, increased frequency of type 2 myocardial infarctions [MIs]), clinical course, and prognosis of ACS in older adults. In general, higher comorbidity burden increases mortality following MI, reduces utilization of ACS treatments, and increases the importance of developing individualized treatment plans.

Multimorbidity in Older Patients with Cardiovascular Disease

Multimorbidity affects more than two thirds of older individuals and the vast majority of patients with chronic cardiovascular disease. Patients with multimorbidity have high resource utilization, poor mobility, and poor health status and are at an increased risk for death. The presence of multimorbidity imposes numerous management challenges in caring for patients with chronic cardiovascular disease. It complicates decision-making, promotes fragmented care, and imposes an immense burden on the patient and their social support system. Novel models of care, such as the cardiovascular patient-centered medical home, are needed to provide high-quality, efficient, effective care to this growing population.

[Multimorbidity patterns in young adults in Catalonia: an analysis of clusters]

Objetivo

Identificar los patrones de multimorbilidad en pacientes de 19-44 años atendidos en atención primaria en Cataluña en el año 2010.

Diseño

Estudio descriptivo transversal.

Emplazamiento

Doscientos cincuenta y un centros de salud.

Participantes

Fueron 530.798 personas con multimorbilidad de 19-44 años.

Mediciones principales

La multimorbilidad fue definida como la coexistencia de ≥2 diagnósticos de la Clasificación Internacional de Enfermedades registrados en la historia clínica informatizada. Los patrones de multimorbilidad fueron identificados a través de un análisis jerárquico de clústeres y descritos por sexo y grupos de edad (19-24 y 25-44 años).

Resultados

De las 882.708 personas de la población inicial, 530.798 (60,1%) presentaron multimorbilidad. La media de edad fue de 33,0 años (DT: 7,0) y el 53,3% fueron mujeres. La multimorbilidad fue más alta en el grupo de 25-44 años respecto al grupo más joven (60,5 vs. 58,1%, p < 0,001), siendo más alta en las mujeres. El clúster más prevalente en todos los estratos estuvo constituido por caries dental, tabaquismo, dorsalgia, resfriado común y otros trastornos de ansiedad. En ambos sexos, en los estratos de 25-44 años apareció el patrón cardiovascular-endocrino-metabólico (obesidad, dislipidemias e hipertensión arterial).

Conclusiones

La multimorbilidad afecta a más de la mitad de personas entre los 19-44 años de edad. El clúster más prevalente está formado por diagnósticos que agrupan enfermedades comunes (caries dental, resfriado común, tabaquismo, trastornos de ansiedad y dorsalgias). Otro patrón a destacar es el cardiovascular-endocrino-metabólico en el grupo de 25-44. El conocimiento de los patrones de multimorbilidad en adultos jóvenes permitiría un enfoque preventivo.

Vitamin K Status and Lower Extremity Function in Older Adults: The Health Aging and Body Composition Study

BACKGROUND

While low vitamin K status has been associated with several chronic diseases that can lead to lower extremity disability, it is not known if low vitamin K status is associated with worse lower extremity function.

METHODS

Vitamin K status was measured according to plasma phylloquinone (vitamin K1) and dephosphorylated-uncarboxylated MGP (dp-ucMGP) in 1,089 community-dwelling older adults (mean ± SD age =74±3 years; 67% female). Lower extremity function was assessed using the short physical performance battery (SPPB), gait speed, and isokinetic leg strength. Linear regression and mixed models were used to determine the cross-sectional and longitudinal associations between vitamin K status and functional outcome measures.

RESULTS

Cross-sectionally, higher plasma phylloquinone was associated with better SPPB scores and 20-m gait speed (p ≤ .05). After 4-5 years, those with ≥1.0nM plasma phylloquinone (the concentration achieved when recommended intakes are met) had better SPPB scores (p = .03) and 20-m gait speed (p < .05). Lower plasma dp-ucMGP (reflective of better vitamin K status) was associated with better SPPB scores and leg strength cross-sectionally (p ≤ .04), but not longitudinally. Neither measure of vitamin K status was associated with walking endurance or with the rate of decline in function.

CONCLUSION

Older adults with higher vitamin K status had better physical performance scores at baseline, but data are less consistent longitudinally. Since lower extremity disability is a common consequence of multiple chronic diseases for which a role of vitamin K has been suggested, future studies are needed to determine if vitamin K supplementation could improve function in those with vitamin K insufficiency and clarify underlying mechanism(s).

Multimorbidity and Risk of Mild Cognitive Impairment

OBJECTIVES

To determine the association between multiple chronic conditions and risk of incident mild cognitive impairment (MCI) and dementia.

DESIGN

Prospective cohort study.

SETTING

Olmsted County, Minnesota.

PARTICIPANTS

Cognitively normal individuals (N = 2,176) enrolled in the Mayo Clinic Study of Aging (MCSA).

MEASUREMENTS

Participants were randomly selected from the community, evaluated by a physician, and underwent neuropsychometric testing at baseline and at 15-month intervals to assess diagnoses of MCI and dementia. Information on International Classification of Diseases, Ninth Revision codes for chronic conditions in the 5 years before enrollment was electronically captured using the Rochester Epidemiology Project medical records linkage system. Multimorbidity was defined as having two or more chronic conditions, and the association between multimorbidity and MCI and dementia was examined using Cox proportional hazards models.

RESULTS

Of 2,176 cognitively normal participants (mean age ± standard deviation 78.5 ± 5.2; 50.6% male), 1,884 (86.6%) had multimorbidity. The risk of MCI or dementia was higher in persons with multimorbidity (hazard ratio (HR) = 1.38, 95% confidence interval (CI) = 1.05-1.82) than in those with one or no chronic condition. The HR was of greater magnitude in persons with four or more conditions (HR = 1.61, 95% CI = 1.21-2.13) than in those with two or three conditions (HR = 1.03, 95% CI = 0.76-1.39) and for men with multimorbidity(HR = 1.53, 95% CI = 1.01-2.31) than for women with multimorbidity (HR = 1.20, 95% CI = 0.83-1.74), compared to those with one or no chronic condition.

CONCLUSION

In older adults, having multiple chronic conditions is associated with greater risk of MCI and dementia. This is consistent with the hypothesis that multiple etiologies may contribute to MCI and late-life dementia. Preventing chronic diseases may be beneficial in delaying or preventing MCI and dementia.

Association of Cardiometabolic Multimorbidity With Mortality

IMPORTANCE

The prevalence of cardiometabolic multimorbidity is increasing.

OBJECTIVE

To estimate reductions in life expectancy associated with cardiometabolic multimorbidity.

DESIGN, SETTING, AND PARTICIPANTS

Age- and sex-adjusted mortality rates and hazard ratios (HRs) were calculated using individual participant data from the Emerging Risk Factors Collaboration (689,300 participants; 91 cohorts; years of baseline surveys: 1960-2007; latest mortality follow-up: April 2013; 128,843 deaths). The HRs from the Emerging Risk Factors Collaboration were compared with those from the UK Biobank (499,808 participants; years of baseline surveys: 2006-2010; latest mortality follow-up: November 2013; 7995 deaths). Cumulative survival was estimated by applying calculated age-specific HRs for mortality to contemporary US age-specific death rates.

EXPOSURES

A history of 2 or more of the following: diabetes mellitus, stroke, myocardial infarction (MI).

MAIN OUTCOMES AND MEASURES

All-cause mortality and estimated reductions in life expectancy.

RESULTS

In participants in the Emerging Risk Factors Collaboration without a history of diabetes, stroke, or MI at baseline (reference group), the all-cause mortality rate adjusted to the age of 60 years was 6.8 per 1000 person-years. Mortality rates per 1000 person-years were 15.6 in participants with a history of diabetes, 16.1 in those with stroke, 16.8 in those with MI, 32.0 in those with both diabetes and MI, 32.5 in those with both diabetes and stroke, 32.8 in those with both stroke and MI, and 59.5 in those with diabetes, stroke, and MI. Compared with the reference group, the HRs for all-cause mortality were 1.9 (95% CI, 1.8-2.0) in participants with a history of diabetes, 2.1 (95% CI, 2.0-2.2) in those with stroke, 2.0 (95% CI, 1.9-2.2) in those with MI, 3.7 (95% CI, 3.3-4.1) in those with both diabetes and MI, 3.8 (95% CI, 3.5-4.2) in those with both diabetes and stroke, 3.5 (95% CI, 3.1-4.0) in those with both stroke and MI, and 6.9 (95% CI, 5.7-8.3) in those with diabetes, stroke, and MI. The HRs from the Emerging Risk Factors Collaboration were similar to those from the more recently recruited UK Biobank. The HRs were little changed after further adjustment for markers of established intermediate pathways (eg, levels of lipids and blood pressure) and lifestyle factors (eg, smoking, diet). At the age of 60 years, a history of any 2 of these conditions was associated with 12 years of reduced life expectancy and a history of all 3 of these conditions was associated with 15 years of reduced life expectancy.

CONCLUSIONS AND RELEVANCE

Mortality associated with a history of diabetes, stroke, or MI was similar for each condition. Because any combination of these conditions was associated with multiplicative mortality risk, life expectancy was substantially lower in people with multimorbidity.

Aging and Multimorbidity: New Tasks, Priorities, and Frontiers for Integrated Gerontological and Clinical Research

Aging is characterized by rising susceptibility to development of multiple chronic diseases and, therefore, represents the major risk factor for multimorbidity. From a gerontological perspective, the progressive accumulation of multiple diseases, which significantly accelerates at older ages, is a milestone for progressive loss of resilience and age-related multisystem homeostatic dysregulation. Because it is most likely that the same mechanisms that drive aging also drive multiple age-related chronic diseases, addressing those mechanisms may reduce the development of multimorbidity. According to this vision, studying multimorbidity may help to understand the biology of aging and, at the same time, understanding the underpinnings of aging may help to develop strategies to prevent or delay the burden of multimorbidity. As a consequence, we believe that it is time to build connections and dialogue between the clinical experience of general practitioners and geriatricians and the scientists who study aging, so as to stimulate innovative research projects to improve the management and the treatment of older patients with multiple morbidities.

Health-enhancing multibehavior and medical multimorbidity

OBJECTIVE

To examine the association of multibehavior on multimorbidity.

PATIENTS AND METHODS

Data from the 2005-2006 National Health and Nutrition Examination Survey were used. The study duration was from October 20, 2013, through December 16, 2014. A multimorbidity index variable was created that indicated the number of 14 morbidities that each patient had. A multibehavior index variable was created that indicated the number of 4 health-enhancing behaviors each participant had; physical activity was assessed via accelerometry, dietary behavior was assessed via an interview, smoking was determined via cotinine levels, and sleep duration was self-reported.

RESULTS

For the entire sample of 2048 participants, those with 1, 2, 3, and 4 health behaviors, compared with 0 health behaviors, had a 35% (odds ratio [OR], 0.65; 95% CI, 0.47-0.90; P=.01), 44% (OR, 0.56; 95% CI, 0.38-0.82; P=.006), 63% (OR, 0.37; 95% CI, 0.26-0.51; P<.001), and 69% (OR, 0.31; 95% CI, 0.19-0.52; P<.001) reduced odds of being multimorbid, respectively. Only physical activity (β=-.46) and sleep (β=-.23) were independently associated with multimorbidity, and only 2 health behavior combinations were associated with multimorbidity: physical activity and sleep (β=-.17) and physical activity and nonsmoking (β=-.16).

CONCLUSIONS

Americans engaging in more health behaviors were less likely to be multimorbid. Physical activity was independently, as well is in combination with other health behaviors, associated with multimorbidity. Implications for developing a multibehavior-multimorbidity framework to treat the patients' holistic needs is discussed.

The increasing burden and complexity of multimorbidity

BACKGROUND

Multimorbidity, the co-occurrence of two or more chronic conditions, is common among older adults and is known to be associated with high costs and gaps in quality of care. Population-based estimates of multimorbidity are not readily available, which makes future planning a challenge. We aimed to estimate the population-based prevalence and trends of multimorbidity in Ontario, Canada and to examine patterns in the co-occurrence of chronic conditions.

METHODS

This retrospective cohort study includes all Ontarians (aged 0 to 105 years) with at least one of 16 common chronic conditions. Descriptive statistics were used to examine and compare the prevalence of multimorbidity by age and number of conditions in 2003 and 2009. The co-occurrence of chronic conditions among individuals with multimorbidity was also explored.

RESULTS

The prevalence of multimorbidity among Ontarians rose from 17.4% in 2003 to 24.3% in 2009, a 40% increase. This increase over time was evident across all age groups. Within individual chronic conditions, multimorbidity rates ranged from 44% to 99%. Remarkably, there were no dominant patterns of co-occurring conditions.

CONCLUSION

The high prevalence of multimorbidity and numerous combinations of conditions suggests that single, disease-oriented management programs may be less effective or efficient tools for high quality care compared to person-centered approaches.

The increasing burden and complexity of multimorbidity

BACKGROUND

Multimorbidity, the co-occurrence of two or more chronic conditions, is common among older adults and is known to be associated with high costs and gaps in quality of care. Population-based estimates of multimorbidity are not readily available, which makes future planning a challenge. We aimed to estimate the population-based prevalence and trends of multimorbidity in Ontario, Canada and to examine patterns in the co-occurrence of chronic conditions.

METHODS

This retrospective cohort study includes all Ontarians (aged 0 to 105 years) with at least one of 16 common chronic conditions. Descriptive statistics were used to examine and compare the prevalence of multimorbidity by age and number of conditions in 2003 and 2009. The co-occurrence of chronic conditions among individuals with multimorbidity was also explored.

RESULTS

The prevalence of multimorbidity among Ontarians rose from 17.4% in 2003 to 24.3% in 2009, a 40% increase. This increase over time was evident across all age groups. Within individual chronic conditions, multimorbidity rates ranged from 44% to 99%. Remarkably, there were no dominant patterns of co-occurring conditions.

CONCLUSION

The high prevalence of multimorbidity and numerous combinations of conditions suggests that single, disease-oriented management programs may be less effective or efficient tools for high quality care compared to person-centered approaches.

Prevalence and structure of multiple chronic conditions in Lithuanian population and the distribution of the associated healthcare resources

BACKGROUND

Chronic multiple conditions have become a major threat to the world's healthcare systems within the last years.

OBJECTIVE

To estimate the prevalence and structure of chronic conditions in Lithuania and to analyse the utilisation of healthcare resources striving to manage patients with multimorbidity.

METHODS

It was based on the National Health Insurance Fund (NHIF) database, that covered the period from January, 2012 to June, 2014 and included 452,769 subjects. The prevalence of multimorbidity in Lithuania, the structure of chronic diseases within the age and gender groups as well as the association between multimorbidity and facilities usage were analysed.

RESULTS

The prevalence of chronic diseases in adult Lithuanian population was 17.2%, where 94.6% (N=428 430) of the chronically diseased subjects had >1 chronic condition. The number of chronic conditions increased with the age, especially at the age of 45-54 years, and male gender (p<0.001). 10% of patients had at least 2 chronic diseases at the age of 45 and over. Multimorbidity accounted for 258,761 additional bed days per year nationally and 61% increase in the 30-day readmission rate. Primary care and outpatient visits per 1000 population were 2.1 times more prevalent and home visits were 9.6 times more frequent in multimorbid patients compared to a single chronic disease.

CONCLUSIONS

Multimorbidity and its increasing prevalence among the younger patients will put additional strain on healthcare resources at an earlier stage by increasing admission, readmission rates and vastly increasing primary care contacts.

A cross-sectional assessment of the prevalence of multiple chronic conditions and medication use in a sample of community-dwelling adults with fibromyalgia in Olmsted County, Minnesota

OBJECTIVES

The objective of this study was to evaluate the problem of multiple chronic conditions and polypharmacy in patients with fibromyalgia.

DESIGN

Retrospective medical record review.

SETTING

Olmsted County, Minnesota.

PARTICIPANTS

1111 adults with fibromyalgia.

PRIMARY AND SECONDARY OUTCOME MEASURES

Number and type of chronic medical and psychiatric conditions, medication use.

RESULTS

Medical record review demonstrated that greater than 50% of the sample had seven or more chronic conditions. Chronic joint pain/degenerative arthritis was the most frequent comorbidity (88.7%), followed by depression (75.1%), migraines/chronic headaches (62.4%) and anxiety (56.5%). Approximately, 40% of patients were taking three or more medications for symptoms of fibromyalgia. Sleep aids were the most commonly prescribed medications in our sample (33.3%) followed by selective serotonin reuptake inhibitors (28.7%), opioids (22.4%) and serotonin norepinephrine reuptake inhibitors (21.0%).

CONCLUSIONS

The results of our study highlight the problem of multiple chronic conditions and high prevalence of polypharmacy in fibromyalgia. Clinicians who care for patients with fibromyalgia should take into consideration the presence of multiple chronic conditions when recommending medications.

Risk of developing multimorbidity across all ages in an historical cohort study: differences by sex and ethnicity

OBJECTIVE

To study the incidence of de novo multimorbidity across all ages in a geographically defined population with an emphasis on sex and ethnic differences.

DESIGN

Historical cohort study.

SETTING

All persons residing in Olmsted County, Minnesota, USA on 1 January 2000 who had granted permission for their records to be used for research (n=123 716).

PARTICIPANTS

We used the Rochester Epidemiology Project medical records-linkage system to identify all of the county residents. We identified and removed from the cohort all persons who had developed multimorbidity before 1 January 2000 (baseline date), and we followed the cohort over 14 years (1 January 2000 through 31 December 2013).

MAIN OUTCOME MEASURES

Incident multimorbidity was defined as the development of the second of 2 conditions (dyads) from among the 20 chronic conditions selected by the US Department of Health and Human Services. We also studied the incidence of the third of 3 conditions (triads) from among the 20 chronic conditions.

RESULTS

The incidence of multimorbidity increased steeply with older age; however, the number of people with incident multimorbidity was substantially greater in people younger than 65 years compared to people age 65 years or older (28 378 vs 6214). The overall risk was similar in men and women; however, the combinations of conditions (dyads and triads) differed extensively by age and by sex. Compared to Whites, the incidence of multimorbidity was higher in Blacks and lower in Asians.

CONCLUSIONS

The risk of developing de novo multimorbidity increases steeply with older age, varies by ethnicity and is similar in men and women overall. However, as expected, the combinations of conditions vary extensively by age and sex. These data represent an important first step toward identifying the causes and the consequences of multimorbidity.

Multimorbidity in heart failure: a community perspective

BACKGROUND

Comorbidities are a major concern in heart failure, leading to adverse outcomes, increased health care utilization, and excess mortality. Nevertheless, the epidemiology of comorbid conditions and differences in their occurrence by type of heart failure and sex are not well documented.

METHODS

The prevalence of 16 chronic conditions defined by the US Department of Health and Human Services was obtained among 1382 patients from Olmsted County, Minn. diagnosed with first-ever heart failure between 2000 and 2010. Heat maps displayed the pairwise prevalences of the comorbidities and the observed-to-expected ratios for occurrence of morbidity pairs by type of heart failure (preserved or reduced ejection fraction) and sex.

RESULTS

Most heart failure patients had 2 or more additional chronic conditions (86%); the most prevalent were hypertension, hyperlipidemia, and arrhythmias. The co-occurrence of other cardiovascular diseases was common, with higher prevalences of co-occurring cardiovascular diseases in men compared with women. Patients with preserved ejection fraction had one additional condition compared with those with reduced ejection fraction (mean 4.5 vs 3.7). The patterns of co-occurring conditions were similar between preserved and reduced ejection fraction; however, differences in the ratios of observed-to-expected co-occurrence were apparent by type of heart failure and sex. In addition, some psychological and neurological conditions co-occurred more frequently than expected.

CONCLUSION

Multimorbidity is common in heart failure, and differences in co-occurrence of conditions exist by type of heart failure and sex, highlighting the need for a better understanding of the clinical consequences of multiple chronic conditions in heart failure patients.