Multimorbidity, health care utilization and costs in an elderly community-dwelling population: a claims data based observational study

Collaboration and guidelines for the coordination of health care for frail older persons with intellectual disability: A national survey of nurses working in municipal care

AIMS

To describe and compare perceptions of collaboration between care providers on the part of three groups of Registered Nurses working in municipal care and having particular responsibility concerning the care of frail older people with intellectual disability (ID); and, furthermore, to investigate the presence of and compliance with guidelines for the coordination of care.

DESIGN

National survey study with cross-sectional design.

METHODS

Nurses (N = 110) with key positions concerning people with ID answered a national questionnaire about collaboration, guidelines and coordinated individual plans. Descriptive and comparative statistical analyses were applied.

RESULTS

The meetings on cooperation and coordination of interventions were attended most frequently by nurses, and least frequently by social workers. The nurses were overall satisfied with the collaboration but perceived shortcomings in the case of inpatient and outpatient psychiatric care. Only in about half of the meetings for making care plans participated the people with intellectual disability and next of kin.

Socioeconomic Inequality in the Use of Long-Term Care among European Older Adults: An Empirical Approach Using the SHARE Survey

The increase in the proportion of elderly people in developed societies has several consequences, such as the rise in demand for long-term care (LTC). Due to cost, inequalities may arise and punish low-income households. Our objective is to examine socioeconomic inequalities in LTC utilization in Europe. We use the last wave from the Survey of Health, Aging, and Retirement in Europe SHARE (Munich Center for the Economics of Ageing, Munich, Germany), dated 2017, to analyze the impact of socioeconomic status (SES) on LTC. For this purpose, we construct logistic models and control for socioeconomic/household characteristics, health status, and region. Then, concentration indices are calculated to assess the distribution of LTC. Moreover, we also analyze horizontal inequity by using the indirect need-standardization process. We use two measures of SES (household net total income and household net wealth) to obtain robust results. Our findings demonstrate that informal care is concentrated among low-SES households, whereas formal care is concentrated in high-SES households. The results for horizontal concentration indices show a pro-rich distribution in both formal and informal LTC. We add new empirical evidence by showing the dawning of deep social inequalities in LTC utilization. Policymakers should implement policies focused on people who need care to tackle socioeconomic inequalities in LTC.

Epidemiology of multimorbidity among people living with HIV in sub-Saharan Africa: a systematic review protocol

INTRODUCTION

Sub-Saharan Africa remains the epicentre of the HIV pandemic, yet enormous knowledge gaps still exist to elicit a comprehensive portrait of multimorbidity and HIV linkage. This study aims to conduct a systematic meta-analysis of peer-reviewed literature to investigate the current status of multimorbidity epidemiology among people living with HIV (PLHIV) in sub-Saharan Africa.

METHODS AND ANALYSIS

Our review will assess observational studies (ie, cohort, case-control and cross-sectional) on multimorbidity associated with HIV/AIDS between 1 January 2005 and 31 October 2020 from sub-Saharan Africa. Databases to be searched include PubMed/MEDLINE, Scopus, Web of Science, Cochrane library, African Index Medicus and African Journals Online. We will also search the WHO clinical trial registry and databases for systematic reviews. The search strategy will involve the use of medical subject headings and key terms to obtain studies on the phenomena of HIV and multimorbidity at high precision. Quality assessment of eligible studies will be ascertained using a validated quality assessment tool for observational studies and risk of bias through sensitivity analysis to identify publication bias. Further, data on characteristics of the study population, multimorbid conditions, epidemiological rates and spatial distribution of multimorbid conditions in PLHIV will be extracted. Heterogeneity of individual studies will be evaluated using the I² statistic from combined effect size estimates. The statistical analysis will be performed using STATA statistical software V.15 and results will be graphically represented on a forest plot.

ETHICS AND DISSEMINATION

Ethical approval is not applicable in this study as it is a systematic review of published literature. The review findings may also be presented at conferences or before other relevant stakeholders.

PROSPERO REGISTRATION NUMBER

CRD42020148668.

Factors Affecting Healthcare Utilization among Patients with Single and Multiple Chronic Diseases

Background

We aimed to investigate the factors affecting healthcare utilization among patients with single and multiple chronic diseases using the Andersen healthcare utilization model.

Methods

We used a combination of the data from the sixth and seventh Korea National Health and Nutrition Survey (2014-2016). The study population was 3,901 patients with single chronic disease and 1,829 patients with multiple chronic diseases as defined by the WHO. Participants were aged 19 yr or older. Multiple regression analysis was employed using the Andersen model to identify factors affecting healthcare utilization (inpatient and outpatient).

Results

According to the Andersen model (comprising predisposing, enabling, and need factors and health behaviors), the factors that increased outpatients with single chronic disease were female, being aged 65 yr or older, having basic livelihood security benefit, immobility, and poor subjective health status. Factors that increased inpatients with single chronic disease were being aged under 65, having private insurance, immobility, poor subjective health status, and nondrinking. Moreover, factors that increased outpatients and inpatients with multiple chronic diseases were female, being aged under 65, immobility, and poor subjective health status and immobility, poor subjective health status, nondrinking, and not engaging in physical activity, respectively.

Conclusion

We identified factors affecting outpatient and inpatient care utilization among patients with single and multiple chronic diseases, using the Andersen healthcare utilization model. The findings can be used as foundational data to develop preventive and management strategies in healthcare utilization among patients with single and multiple chronic diseases.

The disease burden of multimorbidity and its interaction with educational level

Introduction

Policies to adequately respond to the rise in multimorbidity have top-priority. To understand the actual burden of multimorbidity, this study aimed to: 1) estimate the trend in prevalence of multimorbidity in the Netherlands, 2) study the association between multimorbidity and physical and mental health outcomes and healthcare cost, and 3) investigate how the association between multimorbidity and health outcomes interacts with socio-economic status (SES).

Methods

Prevalence estimates were obtained from a nationally representative pharmacy database over 2007–2016. Impact on costs was estimated in a fixed effect regression model on claims data over 2009–2015. Data on physical and mental health and SES were obtained from the National Health Survey in 2017, in which the Katz-10 was used to measure limitations in activities of daily living (ADL) and the Mental Health Inventory (MHI) to measure mental health. SES was approximated by the level of education. Generalized linear models (2-part models for ADL) were used to analyze the health data. In all models an indicator variable for the presence or absence of multimorbidity was included or a categorical variable for the number of chronic conditions. Interactions terms of multimorbidity and educational level were added into the previously mentioned models.

Results

Over the past ten years, there was an increase of 1.6%-point in the percentage of people with multimorbidity. The percentage of people with three or more conditions increased with +2.1%-point. People with multimorbidity had considerably worse physical and mental health outcomes than people without multimorbidity. For the ADL, the impact of multimorbidity was three times greater in the lowest educational level than in the highest educational level. For the MHI, the impact of multimorbidity was two times greater in the lowest than in the highest educational level. Each additional chronic condition was associated with a greater worsening in health outcomes. Similarly, for costs, where there was no evidence of a diminishing impact of additional conditions either. In patients with multimorbidity total healthcare costs were on average €874 higher than in patients with a single morbidity.

Conclusion

The impact of multimorbidity on health and costs seems to be greater in the sicker and lower educated population.

Needs, barriers and facilitators of older adults towards eHealth in general practice: a qualitative study

Background:

The strain on health care services is increasing due to an ageing population and the increasing prevalence of chronic health conditions. eHealth could contribute to optimise effective and efficient care to older adults with one or more chronic health conditions in the general practice.

Aim:

The aim of this study was to identify the needs, barriers and facilitators amongst community-dwelling older adults (60+) suffering from one or more chronic health conditions, in using online eHealth applications to support general practice services.

Methods:

A qualitative study, using semi-structured followed by think-aloud interviews, was conducted in the Netherlands. The semi-structured interviews, supported by an interview guide were conducted and analysed thematically. The think-aloud method was used to collect data about the cognitive process while the participant was completing a task within online eHealth applications. Verbal analysis according to the Chi approach was conducted to analyse the think-aloud interviews.

Findings:

A total of n = 19 older adults with a mean age of 73 years participated. The ability to have immediate contact with the GP on important health issues was identified as an important need. Identified barriers were non-familiarity with the online eHealth applications and a mismatch of user health needs. The low computer experience resulted in non-familiarity with the online eHealth applications. Faltering applications resulted in participants refusing to participate in the use of online eHealth applications. Convenience, efficiency and the instant availability of eHealth via applications were identified as important facilitators.

Conclusion:

To improve the use and acceptability of eHealth applications amongst older adults in the general practice, the applications should be tailored to meet individual needs. More attention should be given to improving the user-friendliness of these applications and to the promotion of the benefits such as facilitating older adults independent living for longer.

The patient at the centre: evidence from 17 European integrated care programmes for persons with complex needs

BACKGROUND

As the prevalence of multi-morbidity increases in ageing societies, health and social care systems face the challenge of providing adequate care to persons with complex needs. Approaches that integrate care across sectors and disciplines have been increasingly developed and implemented in European countries in order to tackle this challenge. The aim of the article is to identify success factors and crucial elements in the process of integrated care delivery for persons with complex needs as seen from the practical perspective of the involved stakeholders (patients, professionals, informal caregivers, managers, initiators, payers).

METHODS

Seventeen integrated care programmes for persons with complex needs in 8 European countries were investigated using a qualitative approach, namely thick description, based on semi-structured interviews and document analysis. In total, 233 face-to-face interviews were conducted with stakeholders of the programmes between March and September 2016. Meta-analysis of the individual thick description reports was performed with a focus on the process of care delivery.

RESULTS

Four categories that emerged from the overarching analysis are discussed in the article: (1) a holistic view of the patient, considering both mental health and the social situation in addition to physical health, (2) continuity of care in the form of single contact points, alignment of services and good relationships between patients and professionals, (3) relationships between professionals built on trust and facilitated by continuous communication, and (4) patient involvement in goal-setting and decision-making, allowing patients to adapt to reorganised service delivery.

CONCLUSIONS

We were able to identify several key aspects for a well-functioning integrated care process for complex patients and how these are put into actual practice. The article sets itself apart from the existing literature by specifically focussing on the growing share of the population with complex care needs and by providing an analysis of actual processes and interpersonal relationships that shape integrated care in practice, incorporating evidence from a variety of programmes in several countries.

Health literacy and age-related health-care utilisation: a multi-dimensional approach

Inefficient health service utilisation puts pressure on health systems and may cause such negative individual consequences as over-medicalisation or exacerbation of health problems. While previous research has considered the key relevance of health literacy (HL) for efficient use of health services, the results of that research have been somewhat inconclusive. Possible reasons for diverging results of prior research may be grounded in different measurement concepts of HL and the disregarding of age-specific effects. This paper analyses the association between individuals’ HL typology based on a two-dimensional concept and indicators of health service utilisation measured by registered data covering the number of doctor visits and medication costs. Our results confirm a significant interaction effect between age and HL typology. The age-related increase in health service utilisation is strongest for individuals with the combination of high subjective HL but low health-related knowledge, while the smallest increase is for individuals with the constellation of high subjective HL combined with high health-related knowledge. Individuals with specific constellations of HL (that is, individuals with high subjective HL but low health-related knowledge) are associated with reduced service utilisation in younger ages but higher service utilisation in later stages of life, compared to other groups. These results are likely to be attributed to a higher external health-related locus of control and more traditional paternalistic role expectations in such groups.

Neighborhood's locality, road types, and residents' multimorbidity: evidence from China's middle-aged and older adults

Background

Neighborhood factors have gained increasing attention, while the association between the neighborhood’s characteristics and multimorbidity has not been clarified. In this study, we aim to depict variations in the number of non-communicable chronic diseases (NCDs) as a function of urban vs. rural settings and road types.

Methods

The present cross-sectional study derived data from the China Health and Retirement Longitudinal Study 2011 National Baseline Survey. Negative binomial regression with clustered robust standard errors was performed to analyze variations in the number of NCDs among 13,414 Chinese middle-aged and older adults. Logistic regression models were employed to investigate the association between neighborhood-level characteristics and each NCD, respectively.

Results

First, over 65% of subjects had at least one NCDs, and over 35% had multimorbidity. Arthritis (33.08%), hypertension (24.54%), and digestive disease (21.98%) were the most prevalent NCDs. Urban vs. rural differences in multimorbidity were fully explained by neighborhood clustering variations (IRR = 1.02, 95% CI, 0.95–1.10). Living with paved roads was associated with a smaller number of NCDs relative to living with unpaved roads (IRR = 0.86, 95% CI, 0.78–0.95). Results from subgroup analyses suggested that in comparison with those living with unpaved roads, individuals living with paved roads respectively had lower odds of chronic lung disease (OR = 0.76, 95% CI, 0.63–0.93), chronic liver disease (OR = 0.74, 95% CI, 0.55–0.99), chronic kidney disease (OR = 0.68, 95% CI, 0.51–0.89), digestive disease (OR = 0.82, 95% CI, 0.69–0.97), arthritis or rheumatism (OR = 0.69, 95% CI, 0.55–0.87), and asthma (OR = 0.67, 95% CI, 0.51–0.88).

Conclusions

Urban vs. rural disparities in multimorbidity appeared to result from within-neighborhoods characteristics. The improvement in neighborhood-level characteristics, such as road pavement, holds promise to alleviate the increasing disease burden of chronic diseases.

Can voucher scheme enhance primary care provision for older adults: cross-sectional study in Hong Kong

BACKGROUND

The Hong Kong government has launched the Elderly Health Care Voucher (EHCV) scheme to facilitate primary care in the private sector for older adults. This study aimed to examine whether voucher use was associated with a shift of healthcare burden from the public to the private sector, vaccine uptake and continuity of care.

METHODS

This cross-sectional survey recruited older adults with ≥3 chronic diseases through convenience sampling from seven general outpatient clinics, seven geriatric day hospitals, and five specialist outpatient clinics of the public healthcare sector in Hong Kong. We used multiple logistic regression to address the study objective.

RESULTS

A total of 1032 patients participated in the survey. We included 714 participants aged 70 or above in the analysis. EHCV use was associated with higher utilization of private primary care services, including general practitioner and family doctor (Adjusted Odds Ratio (AOR) 2.67, 95% Confidence Interval (95%CI) 1.51-4.72) and Chinese medicine clinic (AOR 3.53, 95%CI 1.47-8.49). There were no significant associations of EHCV use with public general outpatient clinic attendance, Accident & Emergency attendance, and hospitalization. Furthermore, EHCV users were more likely to receive pneumococcal vaccination (AOR 2.17, 95%CI 1.22-3.85) and were less likely to visit the same doctors for chronic disease management (AOR 0.10, 95%CI 0.01-0.73).

CONCLUSIONS

While the EHCV may promote private primary care utilization and preventive care, older patients continue to rely on public services and the EHCV may worsen continuity of care. Policy-makers should designate voucher usage for chronic disease management and continuity of care.

Unmet needs of informal carers of the oldest old in Portugal

Oldest-old individuals are a growing segment of the population that faces several challenges in terms of care demands. Informal caregivers experience more or less challenges, namely depending on the support they can access. The present study explores the unmet needs of a sample of informal caregivers of community-dwelling older adults aged 80+ and analyses the association of such needs with sociodemographic information, care-giving context (e.g., length of care),and health characteristics of the caregivers and care receivers (e.g., cognitive status and functionality). We recruited 175 care-giving dyads from the North of Portugal. Descriptive statistics summarised the sample's characteristics. Informal caregivers were mainly women with a mean age of 60.6 years (SD = 9.8). Care receivers' mean age was 88.7 years (SD = 5.6) and were functionally dependent (9.3 points [SD = 7.0] and 27.0 points [SD = 3.5] for Basic and Instrumental Activities of Daily Living, respectively). A thematic analysis of an open-ended question on unmet needs was performed, revealing the presence of unmet needs. The most relevant ones (financial support, caregiver support, primary care/medical specialities, and labour regulation) were further analysed, concerning the care-giving dyad's using Independent Student's t test or Mann-Whitney U Tests, and Chi-squared test or Fisher's Exact test depending on the variable. The most frequent unmet needs were associated with the caregiver's age, care receivers' kinship, number of care-giving hours, the caregiver's gender, professional status, the caregiver strain and medicines intake. Findings suggest the need for establishing policies that ensure adequate sustainability of the provision of informal care that takes into account the needs of care-giving dyads in the planning process.

Cost effectiveness and the role of the National Institute of Health and Care Excellence (NICE) in interventional radiology

Healthcare expenditure is continually increasing and projected to accelerate in the future, with an increasing proportion being spent on interventional radiology. The role of cost effectiveness studies in ensuring the best allocation of resources is discussed, and the role of National Institute of Health and Care Excellence (NICE) in determining this. Issues with demonstrating cost effectiveness have been discussed, and it has been found that there is significant scope for improving cost effectiveness, with suggestions made for how this can be achieved. In this way, more patients can benefit from better treatment given limited healthcare budgets.

Long-term mortality in young and middle-aged adults hospitalised with chronic disease: a Danish cohort study

OBJECTIVES

To examine the long-term outcomes for patients hospitalised with chronic diseases at age 30, 40 or 50 years.

DESIGN

Nationwide, population-based cohort study.

SETTING

All Danish hospitals, 1979-1989, with follow-up through 2014.

PARTICIPANTS

Patients hospitalised during the study period with one, two or three or more chronic diseases and age-matched and sex-matched persons from the general population without chronic disease leading to hospitalisation: age-30 group: 13 857 patients and 69 285 comparators; age-40 group: 24 129 patients and 120 645 comparators; and age-50 group, 37 807 patients and 189 035 comparators.

MAIN OUTCOME MEASURES

Twenty-five-year mortality risks based on Kaplan-Meier estimates, years-of-life-lost (YLLs) and mortality rate ratios based on Cox regression analysis. YLLs were computed for each morbidity level, as well as in strata of income, employment, education and psychiatric conditions.

RESULTS

Twenty-five-year mortality risks and YLLs increased steadily with increasing number of morbidities leading to hospitalisation and age, but the risk difference with general population comparators remained approximately constant across age cohorts. In the age-30 cohort, the risk differences for patients compared with comparators were 35.0% (95% CI 32.5 to 37.5) with two diseases and 62.5% (54.3% to 70.3%) with three or more diseases. In the age-50 cohort, these differences were, respectively, 48.4% (47.4 to 49.3) and 61.7% (60.1% to 63.0%). Increasing morbidity burden augmented YLLs resulting from low income, unemployment, low education level and psychiatric conditions. In the age-30 cohort, YYLs attributable to low income were 2.4 for patients with one disease, 6.2 for patients with two diseases and 11.5 for patients with three or more diseases.

CONCLUSIONS

Among patients with multiple chronic diseases, the risk of death increases steadily with the number of chronic diseases and with age. Multimorbidity augments the already increased mortality among patients with low socioeconomic status.

Multimorbidity, Function, and Cognition in Aging

Multimorbidity is a global health challenge. Here, we define multimorbidity, describe ways multimorbidity is measured, discuss the prevalence of multimorbidity and how it differs across different populations, examine mechanisms of disease and disability, and discuss the effects of multimorbidity on outcomes such as survival and function.

The influence of integrated geriatric outpatient clinics on the health care utilization of older people

Background

The number of people aged greater than 65 years is growing in many countries. Taiwan will be a superaged society in 2026, and health care utilization will increase considerably. Our study aimed to evaluate the efficacy of the geriatric integrated outpatient clinic model for reducing health care utilization by older people.

Methods

This was a retrospective case-control study. Patients aged greater than 65 years seen at the geriatric outpatient clinic (Geri-OPD) and non-geriatric outpatient clinic (non-Geri-OPD) at a single medical centre were age and sex matched. Data on the number of outpatient clinic visits, emergency department visits, hospitalizations and medical expenditures were collected during the first and second years. A subgroup analysis by Charlson comorbidity index (CCI) and older age (age≧80 years) was performed, and the results were compared between the Geri-OPD and non-Geri-OPD groups.

Results

A total of 6723 patients were included (3796 women and 2927 men). The mean age was 80.42 ± 6.39 years. There were 1291 (19.2%) patients in the Geri-OPD group and 5432 (80.8%) patients in the non-Geri-OPD group. After one year of regular follow-up, the Geri-OPD patients showed a significant reduction in the types of drugs included in each prescription (5.62 ± 10.85) and the number of clinic visits per year (18.18 ± 48.85) (P < 0.01). After a two-year follow-up, the number of clinic visits, emergency department visits, and hospitalizations and the annual medical costs were still decreased in the Geri-OPD patients. The Geri-OPD patients had more comorbidities and a higher rate of health care utilization than the non-Geri-OPD patients. In the subgroup analysis, patients with more comorbidities (CCI≧2) and an older age (≧80 years) in the Geri-OPD group showed a significant reduction in health care utilization. The Geri-OPD patients also showed a significant decrease in medical utilization in the second year compared with the non-Geri-POD patients.

Conclusion

The Geri-OPD reduced medical costs, the number of drugs prescribed, and the frequency of outpatient clinic visits, emergency department visits and hospitalizations in older patients with complicated conditions. The effect was even better in the second year.

Patterns of multimorbidity in medical inpatients: a multinational retrospective cohort study

Multimorbidity is frequent and represents a significant burden for patients and healthcare systems. However, there are limited data on the most common combinations of comorbidities in multimorbid patients. We aimed to describe and quantify the most common combinations of comorbidities in multimorbid medical inpatients. We used a large retrospective cohort of adults discharged from the medical department of 11 hospitals across 3 countries (USA, Switzerland, and Israel) between 2010 and 2011. Diseases were classified into acute versus chronic. Chronic diseases were grouped into clinically meaningful categories of comorbidities. We identified the most prevalent combinations of comorbidities and compared the observed and expected prevalence of the combinations. We assessed the distribution of acute and chronic diseases and the median number of body systems in relationship to the total number of diseases. Eighty-six percent (n = 126,828/147,806) of the patients were multimorbid (≥ 2 chronic diseases), with a median of five chronic diseases; 13% of the patients had ≥ 10 chronic diseases. Among the most frequent combinations of comorbidities, the most prevalent comorbidity was chronic heart disease. Other high prevalent comorbidities included mood disorders, arthropathy and arthritis, and esophageal disorders. The ratio of chronic versus acute diseases was approximately 2:1. Multimorbidity affected almost 90% of patients, with a median of five chronic diseases. Over 10% had ≥ 10 chronic diseases. This identification and quantification of frequent combinations of comorbidities among multimorbid medical inpatients may increase awareness of what should be taken into account when treating such patients, a growth in the need for special care considerations.

Medicines use review service in community pharmacies in Spain: REVISA project

Background Community pharmacy services play an important role in controlling some factors related to medicine use and patients can benefit from these services to improve the adherence and knowledge of their medications, besides to reduce medicine-related problems. Objective The aim of the REVISA project is to carry out a study on preliminary implementation of the medicines use review service in Spanish community pharmacies. Setting Sixty-four community pharmacies from all regions of Spain. Method A preliminary implementation, cross-sectional multicentre study was conducted using a convenience sample of voluntary community pharmacies. A structured interview enabled to pharmacists to obtain a better understanding of patient's medicines use. Main outcome measure Medicines use review-related time and cost, satisfaction and willingness to pay. Results A total of 495 patients were enrolled. The mean age of the patients was 66.1 years, with the majority females (56.4%) and a mean consumption of 5.7 medicines. A total of 2811 medicines were evaluated and 550 referral recommendations were made (29.8% to Primary Care). The mean time employed by the pharmacists in the medicines use review service was 52.8 min (medicines use review-related cost of €17.27). Most patients expressed a high level of satisfaction with this service (98.5%) and a willingness to pay for it (84%). Conclusion Medicines use review service in community pharmacies in Spain can be delivered, that it appears to be acceptable to patients and that most patients said they would be willing to pay for it. This service may offer an opportunity to promote inter-professional collaboration between pharmacists and general practitioners.

The role of mental disease on the association between multimorbidity and medical expenditure

BACKGROUND

Multimorbidity is the presence of two or more chronic diseases and is associated with increased adverse outcomes, including hospitalization, mortality and frequency of use of medical institutions.

OBJECTIVE

This study aimed to describe multimorbidity patterns, determine whether multimorbidity was associated with high medical expenditure, and determine whether mental diseases had an interaction effect on this association.

METHODS

We conducted a claims data-based observational study. Data were obtained for 7526 individuals aged 0-75 years from a medical claims data set for Goto, Japan, over a 12-month period (2016-17). Annual medical expenditure was divided into quintiles; the fifth quintile represented high medical expenditure. Multimorbidity status was defined as the occurrence of two or more health conditions from 17 specified conditions. Odds ratios (OR) and 95% confidence intervals (CI) for high medical expenditure were calculated by number of comorbidities.

RESULTS

In total, 5423 (72.1%) participants had multimorbidity. Multimorbidity was significantly associated with high medical expenditure, even after adjustment for age, sex and income category (OR: 10.36, 95% CI: 7.57-14.19; P < 0.001). Mental diseases had a significant interaction effect on the association between multimorbidity and high medical expenditure (P = 0.001).

CONCLUSIONS

Multimorbidity is associated with high medical expenditure in Japan. Mental diseases may contribute to increased medical costs.

Development of an internationally accepted definition of reablement: a Delphi study

With an ageing society, the demand for health and social care is increasing. Traditionally, staff provide care for their clients rather than with them. In contrast, reablement aims to support people to maximise their competences to manage their everyday life as independently as possible. There is considerable variation between and within countries regarding the conceptual understanding of the approach. This variation affects the ability to evaluate reablement approaches systematically, compare and aggregate findings from different studies, and hinders the development of a robust evidence. Therefore, a Delphi study was conducted in 2018/9 with the aim of reaching agreement on the characteristics, components, aims and target groups of reablement, leading towards an internationally accepted definition of reablement. The study consisted of four Web-based survey rounds. In total, 82 reablement experts from 11 countries participated, reaching agreement on five characteristics (e.g. person-centred), seven components (e.g. goal-oriented treatment plan) and five aims (e.g. increase clients’ independency). Furthermore, most experts agreed that reablement is an inclusive approach irrespective of the person's age, capacity, diagnosis or setting. Based on these features, a definition of reablement was developed, which was accepted by 79 per cent of participating experts. This study is a significant step towards providing conceptual clarity about reablement. Future research should focus on evaluating the implementation of agreed reablement components to inform practice, education and policy.

Cognitive Function Is a Prognostic Factor for Mortality of Nursing Home Residents during a 3-Year Observational Period

Introduction

Assessing cognitive function could help to provide appropriate care for nursing home residents. The aim of the study was to identify the factors affecting cognitive function in nursing home residents in Poland and assess how it influenced the mortality rate during a 3-year observational period.

Methods

This study included 202 elderly individuals from a nursing home in 2015. The investigation included examination of cognitive function using the MMSE and bioelectrical impedance analysis. Collected data included sex, age, blood pressure (BP), heart rate, number of comorbidities, years spent in the nursing home, educational level, and cigarette-smoking.

Results

The mean MMSE score was 21.36 ± 6.35, which was negatively correlated with age and diastolic BP (p = 0.001 and p = 0.024, respectively) and positively correlated with body mass, BMI, fat-free mass, fat, muscle mass, and education level (p = 0.004, p = 0.004, p = 002, p = 0.049, p = 0.005, and p ˂ 0.001, respectively). Patients who died during the observational period had lower MMSE scores than those who survived (23.34 ± 5.68 vs. 20.16 ± 6.45; p < 0.001). Smokers had better MMSE results than nonsmokers (23.34 ± 5.98 vs. 20.08 ± 4.94; p < 0.001).

Discussion

Polish nursing home residents had mild cognitive impairment depending on their age, sex, educational level, and nutritional status. Lower MMSE score was a prognostic factor for mortality in the 3-year observational period.

What the doctor doesn't know: Discarded patient knowledge of older adults with multimorbidity

OBJECTIVES

Adherence to treatment has proven to require the involvement of patients in treatment and care planning. This process involves incorporating patient knowledge, or knowledge about the patients' everyday life, into the clinical encounter. This article explores the disclosure practices of such knowledge from older adults with multimorbidity.

METHODS

This was an 18-month qualitative study among 14 older adults with multimorbidity living in Denmark. A thematic analysis was applied, focusing on perceptions of patient knowledge and disclosure practices among the participating patients.

RESULTS

Older adults with multimorbidity have various reasons for not disclosing personal knowledge. The results present three different domains of what we termed discarded patient knowledge: (1) knowledge that had no direct biomedical relevance from participants' perspective; (2) knowledge considered too private; and (3) knowledge assumed to position one as inferior.

DISCUSSION

The participants made judgments on what they believed was welcome in the clinical encounter, framing their knowledge within the purview of biomedicine. Participants' disclosure practices showed that personal knowledge is sometimes not recognized as important for health and care by participants themselves. Knowledge that could have influenced practitioners' understanding of the problem and provided different solutions, is argued to be discarded patient knowledge.

A complex intervention for multimorbidity in primary care: A feasibility study

Aim

To assess the feasibility of a patient-centered complex intervention for multimorbidity (CIM) based on general practice in collaboration with community health-care centers and outpatient clinics.

Methods

Inclusion criteria were age ≥18 years, diagnoses of two or more of three chronic conditions (diabetes, chronic obstructive pulmonary disease (COPD), and chronic heart conditions), and a hospital contact during the previous year. The CIM included extended consultations and nurse care manager support in general practice and intensified cross-sectorial collaboration. Elements included a structured care plan based on patients' care goals, coordination of services, and, if appropriate, shifting outpatient clinic visits to general practice, medication review, referral to rehabilitation, and home care. The acceptability dimension of feasibility was assessed with validated questionnaires, observations, and focus groups.

Results

Forty-eight patients were included (mean age 72.2 (standard deviation (SD) 9.5, range 52-89); 23 (48%) were men. Thirty-seven patients had two diseases; most commonly COPD and cardiovascular disease (46%), followed by diabetes and cardiovascular disease (23%), and COPD and diabetes (15%). Eleven (23%) patients had all three conditions. Focus group interviews with patients with multimorbidity identified three main themes: (1) lack of care coordination existed across health-care sectors before the CIM, (2) extended consultations provided better care coordination, and (3) patients want to be involved in planning their treatment and care. In focus groups, health-care professionals discussed two main themes: (1) patient-centered care and (2) culture and organizational change. Completion rates for questionnaires were 98% (47/48).

Conclusions

Patients and health-care professionals found the CIM acceptable.

Association of patterns of multimorbidity with length of stay: A multinational observational study

The aim of this study was to identify the combinations of chronic comorbidities associated with length of stay (LOS) among multimorbid medical inpatients.Multinational retrospective cohort of 126,828 medical inpatients with multimorbidity, defined as ≥2 chronic diseases (data collection: 2010-2011). We categorized the chronic diseases into comorbidities using the Clinical Classification Software. We described the 20 combinations of comorbidities with the strongest association with prolonged LOS, defined as longer than or equal to country-specific LOS, and reported the difference in median LOS for those combinations. We also assessed the association between the number of diseases or body systems involved and prolonged LOS.The strongest association with prolonged LOS (odds ratio [OR] 7.25, 95% confidence interval [CI] 6.64-7.91, P < 0.001) and the highest difference in median LOS (13 days, 95% CI 12.8-13.2, P < 0.001) were found for the combination of diseases of white blood cells and hematological malignancy. Other comorbidities found in the 20 top combinations had ORs between 2.37 and 3.65 (all with P < 0.001) and a difference in median LOS of 2 to 5 days (all with P < 0.001), and included mostly neurological disorders and chronic ulcer of skin. Prolonged LOS was associated with the number of chronic diseases and particularly with the number of body systems involved (≥7 body systems: OR 21.50, 95% CI 19.94-23.18, P < 0.001).LOS was strongly associated with specific combinations of comorbidities and particularly with the number of body systems involved. Describing patterns of multimorbidity associated with LOS may help hospitals anticipate resource utilization and judiciously allocate services to shorten LOS.

Blessings or burdens: an Interpretative Phenomenological Analysis (IPA) study on the motivations and their impact on end-of-life caregiving among Asian family caregivers

BACKGROUND

While the impact of family caregiving has been well-documented, many of such studies center on investigating external factors such as socioeconomic status, accessibility to resources and availability of social support as the primary causation of caregiver wellbeing outcomes. This paper explores the motivations that drive family caregivers in supporting their family members at the end-of-life, and critically examines how internal appraisal processes of such motivations can both positively and negatively impact their wellbeing.

METHODS

This study adopted an interpretative phenomenological analysis (IPA) to investigate the motivations and internal appraisal processes of Asian family caregivers in Singapore who were tending to a dying family member. Qualitative dyadic interview data (N = 20) was drawn from a larger Randomized Controlled Trial for a novel Family Dignity Intervention (FDI) for palliative care patients and their families. The sampling population consisted of participants aged 21 and above who were identified to be the primary caregivers of older palliative care patients with a prognosis of less than 12 months. Data collection was conducted in the homes of patients and family caregivers.

RESULTS

Findings revealed six themes that could either nurture or diminish caregiver wellbeing: 1) Honoring Fidelity (caregivers were motivated to commit to their caregiving roles in order to avoid regret), 2) Alleviating Suffering (caregivers were motivated to relieve their family member's pain), 3) Enduring Attachment (caregivers were motivated to spend time together with their family member), 4) Preserving Gratitude (caregivers were motivated to express their appreciation to their family member by caregiving), 5) Navigating Change (caregivers were motivated to adapt accordingly to changes in the illness trajectory) and 6) Reconciling with Mortality (caregivers were motivated to respond accordingly to their family member's prognosis). The final theme of the Wellbeing Determinant is posited as an indication of self-determination, and is conjectured to influence how caregiving motivations are appraised by the caregiver.

CONCLUSION

Fulfilling and enhancing one's sense of self-determination appears central to infusing one's caregiving motivations with positive meaning, and consequently nurturing one's wellbeing in the end-of-life caregiving journey. These findings are discussed with recommendations for healthcare professionals working with family caregivers of palliative care patients.

Malnutrition and Food Insecurity Might Pose a Double Burden for Older Adults

Although food insecurity has been associated with a disadvantageous socioeconomic status, especially in older adults, its association with comorbidities is less clear. The scope of the present cross-sectional study was to assess the prevalence of food insecurity among older adults and evaluate the association between food insecurity, malnutrition, chronic disease, multimorbidity and healthcare utilization. A total of 121 older adults (mean (standard deviation) age: 72.6 (8.1)) were recruited from a Primary Care Health Center from 10 August 2019 to 10 September 2019. Food insecurity and malnutrition status were assessed by the Household Food Insecurity Access Scale and Mini Nutritional Assessment tool, respectively. Recorded variables included financial, family data and comorbidities. The prevalence of food insecurity in the sample reached 50.4%, with men and older adults malnourished or at risk for malnutrition, exhibiting high risk for food insecurity. Multimorbidity, frequency of health care utilization and medication adherence were not associated with food insecurity, possibly due to the free health services and remunerated medications offered by the Greek government. However, male gender and malnutrition risk were significant predictors of food insecurity in the multiple logistic analyses. This study highlights the need for mainstreaming food insecurity assessment among older adults with comorbidities, especially those at risk for malnutrition.

A cross-sectional study of Swiss ambulatory care services use by multimorbid patients in primary care in the light of the Andersen model

BACKGROUND

Multimorbidity is frequently encountered in primary care and is associated with increasing use of healthcare services. The Andersen Behavioral Model of Health Services Use is a multilevel framework classifying societal, contextual, and individual characteristics about the use of healthcare services into three categories: 1. predisposing factors, 2. enabling factors, and 3. need factors. The present study aimed to explore multimorbid patients' use of ambulatory healthcare in terms of homecare and other allied health services, visits to GPs, and number of specialists involved. A secondary aim was to apply Andersen's model to explore factors associated with this use.

METHOD

In a cross-sectional study, 100 Swiss GPs enrolled up to 10 multimorbid patients each. After descriptive analyses, we tested the associations of each determinant and outcome variable of healthcare use, according to the Andersen model: predisposing factors (patient's demographics), enabling factors (health literacy (HLS-EU-Q6), deprivation (DipCare)), and need factors (patient's quality of life (EQ-5D-3L), treatment burden (TBQ), severity index (CIRS), number of chronic conditions, and of medications). Logistic regressions (dichotomous variables) and negative binomial regressions (count variables) were calculated to identify predictors of multimorbid patients' healthcare use.

RESULTS

Analyses included 843 multimorbid patients; mean age 73.0 (SD 12.0), 28-98 years old; 48.3% men; 15.1% (127/843) used homecare. Social deprivation (OR 0.75, 95%CI 0.62-0.89) and absence of an informal caregiver (OR 0.50, 95%CI 0.28-0.88) were related to less homecare services use. The use of other allied health services (34.9% (294/843)) was associated with experiencing pain (OR 2.49, 95%CI 1.59-3.90). The number of contacts with a GP (median 11 (IQR 7-16)) was, among other factors, related to the absence of an informal caregiver (IRR 0.90, 95%CI 0.83-0.98). The number of specialists involved (mean 1.9 (SD 1.4)) was linked to the treatment burden (IRR 1.06, 95%CI 1.02-1.10).

CONCLUSION

Multimorbid patients in primary care reported high use of ambulatory healthcare services variably associated with the Andersen model's factors: healthcare use was associated with objective medical needs but also with contextual or individual predisposing or enabling factors. These findings emphasize the importance of adapting care coordination to individual patient profiles.

Translation, cultural adaptation and validation of the Chinese Multimorbidity Treatment Burden Questionnaire(C-MTBQ): a study of older hospital patients

Background

Due to an ageing population, multimorbidity is becoming more common. Treatment burden (the effort required of patients to look after their health and the impact this has on their wellbeing) is prevalent in patients with multimorbidity. The Multimorbidity Treatment Burden Questionnaire (MTBQ) is a patient-reported outcome measure of treatment burden that has been validated amongst patients with multimorbidity in the UK. The aim of this study was to translate and culturally adapt the MTBQ into Chinese and to assess its reliability and validity in elderly patients with multimorbidity in hospital.

Methods

The original English version of the MTBQ was translated into Chinese using Brislin’s model of cross-culture translation. The C-MTBQ was piloted on a sample of 30 elderly patients with multimorbidity prior to being completed by 156 Chinese elderly patients with multimorbidity recruited from a hospital in Zhengzhou, China. We examined the proportion of missing data, the distribution of responses and floor and ceiling effects for each question. Factor analysis, Cronbach’s alpha, intraclass coefficient and Spearman’s rank correlations assessed dimensional structure, internal consistency reliability, test-retest reliability and criterion validity, respectively.

Results

The average age of the respondents was 73.5 years (range 60–99 years). The median C-MTBQ global score was 20.8 (interquartile range 12.5–29.2). Significant floor effects were seen for all items. Factor analysis supported a three-factor structure. The C-MTBQ had high internal consistency (Cronbach’s alpha coefficient, 0.76) and test-retest reliability (the intraclass correlation coefficient, 0.944), the correlations between every item and global scores scored > 0.4. The scale content validity index(S-CVI) was 0.89, and the item level content validity index(I-CVI)was 0.83 ~ 1.00. The criterion validity was 0.875.

Conclusion

The Chinese version of MTBQ showed satisfactory reliability and validity in elderly patients with multimorbidity, and could be used as a tool to measure treatment burden of elderly patients with multimorbidity in hospital.

e-Health interventions for healthy aging: a systematic review

BACKGROUND

Healthy aging (HA) is a contemporary challenge for population health worldwide. Electronic health (e-Health) interventions have the potential to support empowerment and education of adults aged 50 and over.

OBJECTIVES

To summarize evidence on the effectiveness of e-Health interventions on HA and explore how specific e-Health interventions and their characteristics effectively impact HA.

METHODS

A systematic review was conducted based on the Cochrane Collaboration methods including any experimental study design published in French, Dutch, Spanish, and English from 2000 to 2018.

RESULTS

Fourteen studies comparing various e-Health interventions to multiple components controls were included. The target population, type of interventions, and outcomes measured were very heterogeneous across studies; thus, a meta-analysis was not possible. However, effect estimates indicate that e-Health interventions could improve physical activity. Positive effects were also found for other healthy behaviors (e.g., healthy eating), psychological outcomes (e.g., memory), and clinical parameters (e.g., blood pressure). Given the low certainty of the evidence related to most outcomes, these results should be interpreted cautiously.

CONCLUSIONS

This systematic review found limited evidence supporting the effectiveness of e-Health interventions, although the majority of studies show positive effects of these interventions for improving physical activity in older adults. Thus, better quality evidence is needed regarding the effects of e-Health on the physiological, psychological, and social dimensions of HA.

SYSTEMATIC REVIEW REGISTRATION

The review protocol was registered in PROSPERO (registration number: CRD42016033163).

Do Centenarians Die Healthier than Younger Elders? A Comparative Epidemiological Study in Spain

This study aims to describe the clinical course, drug use, and health services use characteristics during the last year of life of elders who die being centenarians and to identify key aspects differentiating them from elders who die at an earlier age, with a particular focus on sex differences. We conducted an observational, population-based study in the EpiChron Cohort (Aragón, Spain). The population was stratified by sex and into three age sub-populations (80-89, 90-99, and ≥100 years), and their characteristics were described and compared. Multimorbidity was the rule in our elders, affecting up to 3 in 4 centenarians and 9 in 10 octogenarians and nonagenarians. Polypharmacy was also observed in half of the centenarian population and in most of the younger elders. Risk factors for cardiovascular disease (i.e., hypertension, dyslipidaemia, diabetes), cerebrovascular disease and dementia were amongst the most common chronic conditions in all age groups, whereas the gastroprotective drugs and antithrombotic agents were the most dispensed drugs. Centenarians presented in general lower morbidity and treatment burden and lower use of both primary and hospital healthcare services than octogenarians and nonagenarians, suggesting a better health status. Sex-differences in their clinical characteristics were more striking in octogenarians and tended to decrease with age.

Multimorbidity among Two Million Adults in China

To explore the multimorbidity prevalence and patterns among middle-aged and older adults from China. Data on thirteen chronic diseases were collected from 2,097,150 participants aged over 45 years between January 1st 2011 and December 31st 2015 from Beijing Medical Claim Data for Employees. Association rule mining and hierarchical cluster analysis were applied to assess multimorbidity patterns. Multimorbidity prevalence was 51.6% and 81.3% in the middle-aged and older groups, respectively. The most prevalent disease pair was that of osteoarthritis and rheumatoid arthritis (OARA) with hypertension (HT) (middle-aged: 22.5%; older: 41.8%). Ischaemic heart disease (IHD), HT, and OARA constituted the most common triad combination (middle-aged: 11.0%; older: 31.2%). Among the middle-aged group, the strongest associations were found in a combination of cerebrovascular disease (CBD), OARA, and HT with IHD in males (lift = 3.49), and CBD, OARA, and COPD with IHD in females (lift = 3.24). Among older patients, glaucoma and cataracts in females (lift = 2.95), and IHD, OARA, and glaucoma combined with cataracts in males (lift = 2.45) were observed. Visual impairment clusters, a mixed cluster of OARA, IHD, COPD, and cardiometabolic clusters were detected. Multimorbidity is prevalent among middle-aged and older Chinese individuals. The observations of multimorbidity patterns have implications for improving preventive care and developing appropriate guidelines for morbidity treatment.

Prevalence of Multimorbidity among Asian Indian, Chinese, and Non-Hispanic White Adults in the United States

Asian Americans are the fastest-growing minority group in the United States, yet little is known about their multimorbidity. This study examined the association of Asian Indians, Chinese and non-Hispanic whites (NHWs) to multimorbidity, defined as the concurrent presence of two or more chronic conditions in the same individual. We used a cross-sectional design with data from the National Health Interview Survey (2012–2017) of Asian Indians, Chinese, and NHWs (N = 132,666). Logistic regressions were used to examine the adjusted association of race/ethnicity to multimorbidity. There were 1.9% Asian Indians, 1.8% Chinese, and 96.3% NHWs. In unadjusted analyses (p < 0.001), 17.1% Asian Indians, 17.9% Chinese, and 39.0% NHWs had multimorbidity. Among the dyads, high cholesterol and hypertension were the most common combination of chronic conditions among Asian Indians (32.4%), Chinese (41.0%), and NHWs (20.6%). Asian Indians (AOR = 0.73, 95% CI = (0.61, 0.89)) and Chinese (AOR = 0.63, 95% CI = (0.53, 0.75)) were less likely to have multimorbidity compared to NHWs, after controlling for age, sex, and other risk factors. However, Asian Indians and Chinese were more likely to have high cholesterol and hypertension, risk factors for diabetes and heart disease.

Magnitude and determinants of multimorbidity and health care utilization among patients attending public versus private primary care: a cross-sectional study from Odisha, India

Background

Multimorbidity in primary care is a challenge not only for developing countries but also for low and medium income countries (LMIC). Health services in LMIC countries are being provided by both public and private health care providers. However, a critical knowledge gap exists on understanding the true extent of multimorbidity in both types of primary care settings.

Methods

We undertook a study to identify multimorbidity prevalence and healthcare utilization among both public and private primary care attendees in Odisha state of India. A total of 1649 patients attending 40 primary care facilities were interviewed using a structured multimorbidity assessment questionnaire collecting information on 22 chronic diseases, medication use, number of hospitalization and number of outpatient visits.

Result

The overall prevalence of multimorbidity was 28.3% and nearly one third of patients of public facilities and one fourth from private facilities had multimorbidity. Leading diseases among patients visiting public facilities included acid peptic diseases, arthritis and chronic back pain. No significant difference in reporting of hypertension and diabetes across the facilities was seen. Besides age, predictors of multimorbidity among patients attending public facilities were, females [AOR: 1.6; 95% CI 1.1–1.3] and non-aboriginal groups [AOR: 1.6; 95%CI 1.1–2.3] whereas, in private females [AOR: 1.6; 95%CI 1.1–2.4], better socioeconomic conditions [AOR 1.4; 95% CI 1.0–2.1] and higher educational status [primary school completed [AOR 2.6; 95%CI 1.6–4.2] and secondary schooling and above [AOR 2.0; 95%CI 1.1–3.6] with reference to no education were seen to be the determinants of multimorbidity. Increased number of hospital visits to public facilities were higher among lower educational status patients [IRR: 1.57; 95% CI 1.13–2.18] whereas, among private patients, the mean number of hospital visits was 1.70 times more in higher educational status [IRR: 1.70; 95%CI 1.01–3.69]. The mean number of medicines taken per day was higher among patients attending private hospitals.

Conclusion

Our findings suggest that, multimorbidity is being more reported in public primary care facilities. The pattern and health care utilization in both types of settings are different. A comprehensive care approach must be designed for private care providers.

Evidence-based quality indicators for primary healthcare in association with the risk of hospitalisation: a population-based cohort study in Switzerland

OBJECTIVES

The quality of ambulatory care in Switzerland is widely unknown. Therefore, this study aimed to evaluate the recently proposed quality indicators (QIs) based on a nationwide healthcare claims database and determine their association with the risk of subsequent hospitalisation at patient-level.

DESIGN

Retrospective cohort study.

SETTING

Inpatient and outpatient claims data of a large health insurance in Switzerland covering all regions and population strata.

PARTICIPANTS

520 693 patients continuously insured during 2015 and 2016.

MEASURES

A total of 24 QIs were obtained by adapting the existing instruments to the Swiss national context and measuring at patient-level. The association between each QI and hospitalisation in the subsequent year was assessed using multiple logistic regression models.

RESULTS

The proportion of patients with good adherence to QIs was high for the secondary prevention of diabetes and myocardial infarction (glycated haemoglobin (HbA1c) control, 89%; aspirin use, 94%) but relatively low for polypharmacy (53%) or using potentially inappropriate medications (PIMs) in the elderly (PIM, 33%). Diabetes-related indicators such as the HbA1c control were significantly associated with a lower risk of hospitalisation (OR, 0.87; 95% CI, 0.80 to 0.95), whereas the occurrence of polypharmacy and PIM increased the risk of hospitalisation in the following year (OR, 1.57/1.08; 95% CI, 1.51 to 1.64/1.05 to 1.12).

CONCLUSIONS

This is the first study to evaluate the recently presented QIs in Switzerland using nationwide real-life data. Our study suggests that the quality of healthcare, as measured by these QIs, varied. The majority of QIs, in particular QIs reflecting chronic care and medication use, are considered beneficial markers of healthcare quality as they were associated with reduced risk of hospitalisation in the subsequent year. Results from this large practical test on real-life data show the feasibility of these QIs and are beneficial in selecting the appropriate QIs for healthcare implementation in general practice.

Video-based tools to enhance nurses' geriatric knowledge: A development and pilot study

BACKGROUND

The need for health care professionals with geriatric knowledge is expected to increase due to aging of society. Educational tools that fit the specific learning styles of nurses and nursing students might be useful for this. Serioussoap.nl (available in Dutch and English) is an educational tool that integrates video-based gaming and storytelling, and it might be an effective way to improve the geriatric knowledge of nurses or nursing students.

OBJECTIVES

To investigate the effect of Serioussoap.nl on the geriatric knowledge of nurses and nursing students, and to evaluate its usability.

DESIGN

We conducted a development and an explorative pilot study, using a pretest posttest quantitative design to investigate the effect of Serioussoap.nl on geriatric knowledge. A qualitative approach was used to evaluate its usability.

PARTICIPANTS AND SETTING

Three vocational nursing schools (n = 119 second/third year students), one baccalaureate nursing university (n = 77 first year vocational nurses) and one home-care organization (n = 44 vocational nurses) in the Netherlands participated in the quantitative study, and 94 vocational students participated in the qualitative study.

METHODS

We measured the effect on geriatric knowledge with the Knowledge of Older People Questionnaire (KOP-Q, score 0-30). The qualitative study included observations of 94 participants while they played Serioussoap.nl, four semi-structured focus groups and eleven individual interviews.

RESULTS

The study demonstrated a significant increase of geriatric knowledge of 7.8% (+2.3 score on the KOP-Q, 95% Confidence Interval (1.4-3.2, p < 0.001). The qualitative data showed that Serioussoap.nl contributed to the reflective learning-style and enhanced meaningful learning.

CONCLUSION

Serioussoap.nl increased the students' geriatric knowledge and was perceived as a suitable and effective educational tool for vocational nursing students and nurses.

Drivers of care costs and quality in the last 3 months of life among older people receiving palliative care: A multinational mortality follow-back survey across England, Ireland and the United States

BACKGROUND

Care costs rise towards the end of life. International comparison of service use, costs and care experiences can inform quality and improve access.

AIM

The aim of this study was to compare health and social care costs, quality and their drivers in the last 3 months of life for older adults across countries. Null hypothesis: no difference between countries.

DESIGN

Mortality follow-back survey. Costs were calculated from carers' reported service use and unit costs.

SETTING

Palliative care services in England (London), Ireland (Dublin) and the United States (New York, San Francisco).

PARTICIPANTS

Informal carers of decedents who had received palliative care participated in the study.

RESULTS

A total of 767 questionnaires were returned: 245 in England, 282 in Ireland and 240 in the United States. Mean care costs per person with cancer/non-cancer were US$37,250/US$37,376 (the United States), US$29,065/US$29,411 (Ireland), US$15,347/US$16,631 (England) and differed significantly (F = 25.79/14.27, p < 0.000). Cost distributions differed and were most homogeneous in England. In all countries, hospital care accounted for > 80% of total care costs; community care 6%-16%, palliative care 1%-15%; 10% of decedents used ~30% of total care costs. Being a high-cost user was associated with older age (>80 years), facing financial difficulties and poor experiences of home care, but not with having cancer or multimorbidity. Palliative care services consistently had the highest satisfaction.

CONCLUSION

Poverty and poor home care drove high costs, suggesting that improving community palliative care may improve care value, especially as palliative care expenditure was low. Major diagnostic variables were not cost drivers. Care costs in the United States were high and highly variable, suggesting that high-cost low-value care may be prevalent.

Comorbidity in lung cancer patients and its association with medical service cost and treatment choice in China

Background

It is evident that comorbidity exacerbate the complexity of the management of lung cancer, however, limited research has been conducted to investigate the impact of comorbidity on health service utilization and cost, as well as the treatment choice among lung cancer patients. We examined the association of comorbidity with medical service utilization, cost and treatment choice among lung cancer patients in China.

Methods

We used claims data from China Urban Employees’ Basic Medical Insurance (UEBMI) and Urban Residents’ Basic Medical Insurance (URBMI) between 2013 to 2016 and data from Hospital Information System (HIS) Database in Beijing Cancer Hospital (BCH). Elixhauser Comorbidity Index was used to assess comorbidity. Negative binomial regression, generalized linear model (GLM) with a gamma distribution and a log link, and logistic regression was applied to assess the associations between comorbidity and medical service utilization, cost and treatment choice, respectively.

Results

Among 8655 patients with lung cancer, 31.3% of had at least one comorbid conditions. Having comorbidity was associated with increased number of annual outpatient visits (1.6, 95%CI: 1.3, 1.9) and inpatients admissions (0.8, 95%CI, 0.70, 0.90), increased outpatient (USD635.5, 95%CI: 490.3, 780.8) and inpatient expenditure (USD2 470.3, 95CI%: 1998.6, 2941.9), as well as increased possibility of choosing radio therapy (OR: 1.208, 95%CI:1.012–1.441) and chemotherapy (1.363, 1.196–1.554), and decreased possibility of choosing surgery (0.850, 0.730–0.989). The medical utilization and expenditure, the possibility of choosing radiotherapy increases, and the possibility of choosing surgery decreases with the increasing number of chronic conditions. There are variations in the association with medical service utilization and expenditure, and treatment choice among individuals with different types of comorbid conditions.

Conclusion

Comorbidity among lung cancer patients restricts the potential treatment choices and poses an extra substantial health care burden. Our findings provide implications for both the clinical management and health service planning and financing for lung cancer patients.

Patterns of Multimorbidity and Differences in Healthcare Utilization and Complexity Among Acutely Hospitalized Medical Patients (≥65 Years) - A Latent Class Approach

PURPOSE

The majority of acutely admitted older medical patients are multimorbid, receive multiple drugs, and experience a complex treatment regime. To be able to optimize treatment and care, we need more knowledge of the association between different patterns of multimorbidity and healthcare utilization and the complexity thereof. The purpose was therefore to investigate patterns of multimorbidity in a Danish national cohort of acutely hospitalized medical patients aged 65 and older and to determine the association between these multimorbid patterns with the healthcare utilization and complexity.

PATIENTS AND METHODS

Longitudinal cohort study of 129,900 (53% women) patients. Latent class analysis (LCA) was used to develop patterns of multimorbidity based on 22 chronic conditions ascertained from Danish national registers. A latent class regression was used to test for differences in healthcare utilization and healthcare complexity among the patterns measured in the year leading up to the index admission.

RESULTS

LCA identified eight distinct multimorbid patterns. Patients belonging to multimorbid patterns including the major chronic conditions; diabetes and chronic obstructive pulmonary disease was associated with higher odds of healthcare utilization and complexity than the reference pattern ("Minimal chronic conditions"). The pattern with the highest number of chronic conditions did not show the highest healthcare utilization nor complexity.

CONCLUSION

Our study showed that chronic conditions cluster together and that these patterns differ in healthcare utilization and complexity. Patterns of multimorbidity have the potential to be used in epidemiological studies of healthcare planning but should be confirmed in other population-based studies.

Determinants of Overnight Stay in Health Centres and Length of Admission: A Study of Canadian Seniors

This study examines the influence of chronic health conditions and socio-economic status on overnight admission and length of stay among Canadian seniors. Incremental multivariate logistic and zero-inflated negative binomial regression models assessed the relationship between selected predictors, overnight admission, and duration of stay. The findings show that all chronic health conditions and socio-economic factors examined were significantly associated with overnight hospital admission. However, seniors with cardiovascular health conditions, the very old, and seniors living in lower-income households had a greater risk of longer stays. Canadian seniors diagnosed with hypertension, cancer, diabetes, and stroke had greater risk of longer overnight hospital stays. Seniors aged 75 to 79 years, 80 years or older, and those living in lower-income households (≤ $39,999) were more likely to have a longer overnight hospital stay. Findings suggest that improving seniors' health and socio-economic status may reduce the risk of overnight admission and longer stays of hospitalisation.

Differences in medical specialist utilization among older people in need of long-term care - results from German health claims data

BACKGROUND

Elderly in need of long-term care tend to have worse health and have higher need of medical care than elderly without need for long-term care. Yet, characteristics associated with long-term care need can impede health care access: Higher levels of long-term care need come with physical and cognitive decline such as frailty and memory loss. Yet, it has not been investigated whether level of long-term care need is related to medical care utilization.

METHODS

We investigated the association between the level of long-term care and medical specialist utilization among nursing home residents and home care recipients. We applied zero-inflated Poisson regression with robust standard errors based on a sample of statutory health insurance members. The sample consisted of 100.000 elderly over age 60. We controlled for age, gender, morbidity and mortality, residential density, and general practitioner utilization.

RESULTS

We found a strong gradient effect of the level of long-term care for 9 out of 12 medical specialties: A higher level of long-term care need was associated with a lower probability of having a medical specialist visit. Yet, we did not find clear effects of the level of long-term care need on the intensity of medical specialist care. These findings were similar for both the nursing home and home care setting.

CONCLUSION

The findings indicate that inequalities in medical specialist utilization exist between elderly with differing levels of long-term care need because differences in morbidity were controlled for. Elderly with higher need of long-term care might face more access barriers to specialist medical care.

Healthcare use in patients with multimorbidity

BACKGROUND

The existence of multiple chronic conditions in the same patient is a public health problem increasingly recognized as relevant to health systems. Individuals with multimorbidity have additional health needs, which imply a heavy burden in healthcare use. It is estimated that between 70% and 80% of the total health expenditure is used with chronic conditions. Patients with multimorbidity are responsible for up to 75% of primary care appointments. These patients are also high hospital users, with up to 14.6 times more risk of hospitalization.

METHODS

This study analyses the association between healthcare use and multimorbidity in the Portuguese population aged 25-74 years old. The association between socioeconomic variables and healthcare use was studied, based on data from the first Portuguese Health Examination Survey using a logistic regression model, stratified by sex and adjusted for socioeconomic confounding variables.

RESULTS

In patients with multimorbidity, there was a greater use of primary healthcare consultations, medical or surgical specialist consultations and hospitalizations. An association was established between female, older age groups and lower educational levels, and increased healthcare use. When adjusted to socioeconomic variables, the likelihood of using healthcare services can be as high as 3.5 times, when compared to patients without chronic conditions.

CONCLUSION

Our results show a greater healthcare use in multimorbidity patients, both in primary and hospital care. The availability of scientific evidence regarding the use of healthcare services by multimorbidity patients may support health policy changes, which could allow a more efficient management of these patients.

Era of geriatric medical challenges: Multimorbidity among older patients

The number of older adults is increasing worldwide, including in Asian countries. Various problems associated with medical care for older adults are being highlighted in aging societies. As the number of chronic diseases increases with age, older adults are more likely to have multiple chronic diseases simultaneously (multimorbidity). Multimorbidity results in poor health-related outcomes, leading to increased use and cost of healthcare. Above all, it leads to deterioration in older adults' quality of life. However, it is unclear whether any medical interventions are effective for multimorbidity, which means medical practitioners currently offer medical care "in the dark." It is therefore necessary for researchers and medical professionals involved in geriatric medicine to establish ways to manage multimorbidity among older adults. This means that the development of research in this field is essential. Geriatr Gerontol Int 2019; 19: 699-704.

Comorbidity prevalence among cancer patients: a population-based cohort study of four cancers

BACKGROUND

The presence of comorbidity affects the care of cancer patients, many of whom are living with multiple comorbidities. The prevalence of cancer comorbidity, beyond summary metrics, is not well known. This study aims to estimate the prevalence of comorbid conditions among cancer patients in England, and describe the association between cancer comorbidity and socio-economic position, using population-based electronic health records.

METHODS

We linked England cancer registry records of patients diagnosed with cancer of the colon, rectum, lung or Hodgkin lymphoma between 2009 and 2013, with hospital admissions records. A comorbidity was any one of fourteen specific conditions, diagnosed during hospital admission up to 6 years prior to cancer diagnosis. We calculated the crude and age-sex adjusted prevalence of each condition, the frequency of multiple comorbidity combinations, and used logistic regression and multinomial logistic regression to estimate the adjusted odds of having each condition and the probability of having each condition as a single or one of multiple comorbidities, respectively, by cancer type.

RESULTS

Comorbidity was most prevalent in patients with lung cancer and least prevalent in Hodgkin lymphoma patients. Up to two-thirds of patients within each of the four cancer patient cohorts we studied had at least one comorbidity, and around half of the comorbid patients had multiple comorbidities. Our study highlighted common comorbid conditions among the cancer patient cohorts. In all four cohorts, the odds of having a comorbidity and the probability of multiple comorbidity were consistently highest in the most deprived cancer patients.

CONCLUSIONS

Cancer healthcare guidelines may need to consider prominent comorbid conditions, particularly to benefit the prognosis of the most deprived patients who carry the greater burden of comorbidity. Insight into patterns of cancer comorbidity may inform further research into the influence of specific comorbidities on socio-economic inequalities in receipt of cancer treatment and in short-term mortality.

Best Definitions of Multimorbidity to Identify Patients With High Health Care Resource Utilization

Objective

To compare different definitions of multimorbidity to identify patients with higher health care resource utilization.

Patients and Methods

We used a multinational retrospective cohort including 147,806 medical inpatients discharged from 11 hospitals in 3 countries (United States, Switzerland, and Israel) between January 1, 2010, and December 31, 2011. We compared the area under the receiver operating characteristic curve (AUC) of 8 definitions of multimorbidity, based on International Classification of Diseases codes defining health conditions, the Deyo-Charlson Comorbidity Index, the Elixhauser-van Walraven Comorbidity Index, body systems, or Clinical Classification Software categories to predict 30-day hospital readmission and/or prolonged length of stay (longer than or equal to the country-specific upper quartile). We used a lower (yielding sensitivity ≥90%) and an upper (yielding specificity ≥60%) cutoff to create risk categories.

Results

Definitions had poor to fair discriminatory power in the derivation (AUC, 0.61-0.65) and validation cohorts (AUC, 0.64-0.71). The definitions with the highest AUC were number of (1) health conditions with involvement of 2 or more body systems, (2) body systems, (3) Clinical Classification Software categories, and (4) health conditions. At the upper cutoff, sensitivity and specificity were 65% to 79% and 50% to 53%, respectively, in the validation cohort; of the 147,806 patients, 5% to 12% (7474 to 18,008) were classified at low risk, 38% to 55% (54,484 to 81,540) at intermediate risk, and 32% to 50% (47,331 to 72,435) at high risk.

Conclusion

Of the 8 definitions of multimorbidity, 4 had comparable discriminatory power to identify patients with higher health care resource utilization. Of these 4, the number of health conditions may represent the easiest definition to apply in clinical routine. The cutoff chosen, favoring sensitivity or specificity, should be determined depending on the aim of the definition.

Patients with more comorbidities have better detection of chronic conditions, but poorer management and control: findings from six middle-income countries

BACKGROUND

The burden of non-communicable diseases (NCDs) is rising rapidly in middle-income countries (MICs), where NCDs are often undiagnosed, untreated and uncontrolled. How comorbidity impacts diagnosis, treatment, and control of NCDs is an emerging area of research inquiry and have important clinical implications as highlighted in the recent National Institute for Health and Care Excellence guidelines for treating patients suffering from multiple NCDs. This is the first study to examine the association between increasing numbers of comorbidities with being undiagnosed, untreated, and uncontrolled for NCDs, in 6 large MICs.

METHODS

Cross-sectional analysis of the World Health Organisation Study of Global Ageing and Adult Health (WHO SAGE) Wave 1 (2007-10), which consisted of adults aged ≥18 years from 6 populous MICs, including China, Ghana, India, Mexico, Russia and South Africa (overall n = 41, 557).

RESULTS

A higher number of comorbidities was associated with better odds of diagnosis for hypertension, angina, and arthritis, and higher odds of having treatment for hypertension and angina. However, more comorbidities were associated with increased odds of uncontrolled hypertension, angina, arthritis, and asthma. Comorbidity with concordant conditions was associated with improved diagnosis and treatment of hypertension and angina.

CONCLUSION

Patients with more comorbidities have better diagnosis of chronic conditions, but this does not translate into better management and control of these conditions. Patients with multiple NCDs are high users of health services and are at an increased risk of adverse health outcomes. Hence, improving their access to care is a priority for healthcare systems.

Experiences and support needs of informal caregivers of people with multimorbidity: a scoping literature review

Objective: Describe and synthesise existing published research on the experiences and support needs of informal caregivers of people with multimorbidity.Design: Scoping literature review. Primary database and secondary searches for qualitative and/or quantitative English-language research with an explicit focus on informal carers of people with multimorbidity (no date restrictions). Quality appraisal of included papers. Thematic analysis to identify key themes in the findings of included papers.Results: Thirty-four papers (reporting on 27 studies) were eligible for inclusion, the majority of which were rated good quality, and almost half of which were published from 2015 onwards. The review highlights common difficulties for informal carers of people with multiple chronic illnesses, including practical challenges related to managing multiple health care teams, appointments, medications and side effects, and psychosocial challenges including high levels of psychological symptomatology and reduced social connectedness. Current gaps in the literature include very few studies of interventions which may help support this caregiver group.Conclusion: Interest in this research area is burgeoning. Future work might fruitfully examine the potential benefits of audio-recorded health care consultations, and digitally delivered psychosocial interventions such as online peer support forums, for supporting and enhancing the caring activities and wellbeing of this caregiver group.

Waiting Time as an Indicator for Health Services Under Strain: A Narrative Review

As pressure increases on public health systems globally, a potential consequence is that this is transferred to patients in the form of longer waiting times to receive care. In this review, we overview what waiting for health care encompasses, its measurement, and the data available in terms of trends and comparability. We also discuss whether waiting time is equally distributed according to socioeconomic status. Finally, we discuss the policy implications and potential approaches to addressing the burden of waiting time. Waiting time for elective surgery and emergency department care is the best described type of waiting time, and it either increases or remains unchanged across multiple developed countries. There are many challenges in drawing direct comparisons internationally, as definitions for these types of waiting times vary. There are less data on waiting time from other settings, but existing data suggest waiting time presents a significant barrier to health care access for a range of health services. There is also evidence that waiting time is unequally distributed to those of lower socioeconomic status, although this may be improving in some countries. Further work to better clarify definitions, identify driving factors, and understand hidden waiting times and identify opportunities for reducing waiting time or better using waiting time could improve health outcomes of our health services.

A Multicenter Study of Multimorbidity in Older Adult Inpatients in China

OBJECTIVES

Multimorbidity is common in older hospitalized adults. To date, however, few studies have addressed multimorbidity in the older population of Chinese inpatients. We aimed to investigate the multimorbidity rate and associated risk factors in older adult inpatients in China.

DESIGN, SETTING, PARTICIPANTS

This study was conducted in the medical wards of a tertiary-care hospital from. The patients were recruited aged between 60 to 101 (74.14±8.46) years.

MEASUREMENTS

Data were obtained from the China Comprehensive Geriatric Assessment Study, conducted in 2011-2012 in China. A total of 4,633 inpatients older than 60 years was recruited from 12 hospitals in 7 cities throughout China. The prevalence of comorbidity, distribution of common chronic diseases, and the associated risk factors were studied.

RESULTS

A total of 4,348 people aged 60 to 101 (74.14±8.46) years completed questionnaires. The average frequency of multimorbidity was 69.3% (95% CI, 67.9% to 70.6%). The prevalence of multimorbidity increased with age and was higher in men (71.6%; 95% CI, 69.9% to 73.3%) than in women (65.3%, 95% CI 63.0% to 67.6%), and higher in the northern region (71.7%, 95% CI 69.9% to 73.5%) than in the southern region (66.0%; 95% CI, 63.8% to 68.1%). The most frequent chronic diseases were hypertension, coronary heart disease, diabetes, cataract, and stroke. Area (OR=0.556; 95% CI, 0.465 to 0.666), region (OR=0.834; 95% CI, 0.723 to 0.962), body mass index (BMI) (OR=1.124; 95% CI, 1.017 to 1.242), and impairment of activities of daily living (OR=0.911; 95% CI, 0.855 to 0.970) were independent factors associated with multimorbidity.

CONCLUSIONS

Multimorbidity is common in older Chinese inpatients with a national prevalence of 69.3% that increases in line with age. Age, region, area, BMI, and daily activities were independent factors significantly associated with multimorbidity in older inpatients. Clinicians should therefore focus more attention on multimorbidity.