Future of Multimorbidity Research: How Should Understanding of Multimorbidity Inform Health System Design?

Quality indicators for ambulatory care for older adults with diabetes and comorbid conditions: A Delphi study

Background

An increasing number of people are living with multiple chronic conditions and it is unclear which quality indicators should be used to guide care for this population.

Objective

To critically appraise and select the most appropriate set of quality indicators for ambulatory care for older adults with five selected disease combinations.

Methods

A two-round web-based Delphi process was used to critically appraise and select quality of care indicators for older adults with diabetes and comorbidities. A fifteen-member Canadian expert panel with broad geographical and clinical representation participated in this study. The panel evaluated process indicators for meaningfulness, potential for improvements in clinical practice, and overall value of inclusion, while outcome indicators were evaluated for importance, modifiability and overall value of inclusion. A 70% agreement threshold was required for high consensus, and 60–69% for moderate consensus as measured on a 5-point Likert type scale.

Results

Twenty high-consensus and nineteen medium-consensus process and outcome indicators were selected for assessing care for older adults with selected disease combinations, including 1) concordant (conditions with a common management plan), 2) discordant (conditions with unrelated management plans), and 3) both types. Panelists reached rapid consensus on quality indicators for care for older adults with concordant comorbid conditions, but not for those with discordant conditions. All selected indicators assess clinical aspects of care. The feedback from the panelists emphasized the importance of developing indicators related to patient-centred aspects of care, including patient self-management, education, patient-physician relationships, and patient’s preferences.

Conclusions

The selected quality indicators are not intended to provide a comprehensive tool set for measuring quality of care for older adults with selected disease combinations. The recommended indicators address clinical aspects of care and can be used as a starting point for ambulatory care settings and development of additional quality indicators.

Feasibility study of goal setting discussions between older adults and volunteers facilitated by an eHealth application: development of the Health TAPESTRY approach

BACKGROUND

In keeping with the changing needs of the Canadian population, primary care systems need to become more person-focused in providing quality care to older adults. As part of Health TAPESTRY, a complex intervention to strengthen primary care for older adults, a goal setting exercise was developed and tested in an initial feasibility study, intended to foster collaboration between patients and providers.

METHODS

Participants-clinic clients-were recruited from the McMaster Family Health Team in Hamilton, Ontario. Five participants took part in the goal setting feasibility study phase I, which tested the functionality of a technology-enabled goal setting exercise between older adults and volunteers. Based on observations and feedback from volunteers, interprofessional team members, and older adults, the exercise was refined to include a guided survey and goals report. The goal setting survey is a list of probing questions designed based on SMART (specific, measurable, attainable, relevant, timely) goal setting strategies and goal attainment scaling (GAS). This was used in phase II, carried out with 16 participants, where the feasibility of goal setting and goal attainment with support from volunteers and interprofessional teams was tested. Volunteers carried out the goal setting survey via a tablet computer, a report of client goals was generated and sent to interprofessional teams, and client goals were discussed during clinic huddles. At 6 months of follow-up, clients self-evaluated their progress using GAS.

RESULTS AND DISCUSSION

The goal setting exercise in phase I took an average of 24:45 (SD 11:42) minutes and yielded a diverse set of life and health goals. Goals identified by older adults were primarily focused on the maintenance of a certain level of activity or health state. Phase I work resulted in important changes to the goal setting process (e.g., asking about goal setting later in conversation, changing wording of questions) and development of a summary report of goals sent to the interprofessional team. In phase II, 44 goals were set by 16 participants during an average 7:23 (SD 4:26) minute discussion. Of these goals, 43.9% were characterized as health goals while 63.4% were characterized as life goals. Under the umbrella of Life goals, productivity featured most prominently at 22.9% of all goals. Goal attainment was not measured in phase I. In phase II, clients had an average weighted goal attainment score of 51.5. Considering client preferences for one goal over another, 68.8% of clients, on average, at least partially achieved the goals they had set.

CONCLUSION

Goal setting as part of the Health TAPESTRY approach was feasible and provided interprofessional teams with client narratives that helped improve care management for older adults. The overall intervention-including the refined goal setting component-is being scaled and evaluated in a pragmatic randomized controlled trial.

Beyond the grey tsunami: a cross-sectional population-based study of multimorbidity in Ontario

OBJECTIVES

To determine volumes and rates of multimorbidity in Ontario by age group, sex, material deprivation, and geography.

METHODS

A cross-sectional population-based study was completed using linked provincial health administrative databases. Ontario residents were classified as having multimorbidity (3+ chronic conditions) or not, based on the presence of 17 chronic conditions. The volumes (number of residents) of multimorbidity were determined by age categories in addition to crude and age-sex standardized rates.

RESULTS

Among the 2013 Ontario population, 15.2% had multimorbidity. Multimorbidity rates increased across successively older age groups with lowest rates observed in youngest (0-17 years, 0.2%) and highest rates in the oldest (80+ years, 73.5%). The rate of multimorbidity increased gradually from ages 0 to 44 years, with a substantial and graded increase in the rates as the population aged. The top five chronic conditions, of the 17 examined, among those with multimorbidity were mood disorders, hypertensive disorders, asthma, arthritis, and diabetes.

CONCLUSION

Much of the common rhetoric around multimorbidity concerns the aging 'grey tsunami'. This study demonstrated that the volume of multimorbidity is derived from adults beginning as young as age 35 years old. A focus only on the old underestimates the absolute burden of multimorbidity on the health care system. It can mask the association of material deprivation and geography with multimorbidity which can turn our attention away from two critical issues: (1) potential inequality in health and health care in Ontario and (2) preventing younger and middle-aged people from moving into the multimorbidity category.

Distinguishing Comorbidity, Disability, and Frailty

PURPOSE OF REVIEW

Over half of the older adults in U.S. have multimorbidity, defined broadly as the presence of 2 or more chronic diseases in an individual. Multimorbidity has significant overlap with disability and frailty. In this review, we broadly review the concepts of multimorbidity, disability, and frailty, as well as their interrelationships, and ability to predict future adverse health outcomes in older adults.

RECENT FINDINGS

Depending on the study, the prevalence of individuals with all three of multimorbidity, disability, and frailty ranges from 2-20%. Multimorbidity and patterns of multimorbidity are predictive of functional limitations, disability, health care usage, and mortality. The degree to which multimorbidity predicts these outcomes depends on many factors but partly upon the population examined and the presence of frailty and disability.

SUMMARY

Multimorbidity is an emerging public health concern that is observed with and predictive of disability and frailty.

Medical multimorbidity and drug use among adults in the United States

Adults with medical multimorbidity (≥2 chronic conditions) present challenges for health care systems to provide coordinated care. Substance use can complicate the management of chronic medical conditions, but little research has focused on the intersection of medical multimorbidity and substance use. This study uses cross-sectional analysis of 115,335 adult respondents of the 2012-2014 administrations of the National Survey on Drug Use and Health to estimate the prevalence and correlates of past-year drug use among adults with multimorbidity. The prevalence of past-year drug use was compared between individuals reporting 0, 1, and ≥2 chronic medical conditions. We used multivariable logistic regression to determine correlates of past-year drug use among adults with ≥2 chronic medical conditions. 53.1% reported no chronic conditions, 29.5% reported one chronic condition, and 17.4% reported ≥2 chronic conditions. Past-year drug use was reported by 18.3% of those with no chronic conditions, 14.8% with 1 chronic condition, and 11.6% with ≥2 chronic conditions. Cannabis and opioid analgesics (nonmedical use) were the most common drugs used across all three groups. In the adjusted model, among adults with medical multimorbidity, adults with past-year drug use were more likely to be younger, male, have lower income, and report current tobacco use, alcohol dependence, past-year depression, and having received mental health treatment in the past year. In this national cohort, fewer adults with multimorbidity reported substance use compared to adults with no or one chronic condition, however, this population with high multimorbidity may be particularly vulnerable to the negative effects of drug use.

Subjective health status of multimorbidity: verifying the mediating effects of medical and assistive devices

Background

This study aimed to verify the mediating effect of using assistive devices as a factor that alleviates the relationship between multimorbidity and subjective health status.

Methods

This study used three-year data (2011–2013) from the Korea Health Panel (KHP). The data were jointly collected by the consortium of the National Health Insurance Service and Korea Institute for Health and Social Affairs.

Results

The mediating effect of using assistive devices was verified, but the direction of the effect was deteriorated subjective health. In other words, in terms of the impact of multimorbidity on subjective health, using assistive devices had a negative impact (−) on subjective health.

Conclusions

The current assessment system for medical devices, narrow scope for choice of assistive devices, and limited scope of health insurance benefits must change to ultimately lead to a positive mediating effect on using medical devices and on subjective health satisfaction of patients with chronic diseases. A system that embraces all ages and generations must be developed. To this end, it is necessary to expand the scope of medical devices and insurance payment in long-term care insurance for elderly users, as well as the active meaning of medical devices in terms of health insurance.

Mental health multimorbidity and poor quality of life in patients with schizophrenia

OBJECTIVE

While "dual diagnosis" involving both psychiatric and substance use disorders has long been a focus of schizophrenia research, recent studies have advocated for a shift of focus to multimorbidity, addressing comorbidity from both additional psychiatric disorders and substance use disorders. We hypothesized that more extensive mental health multimorbity would be associated with poorer quality of life (QOL) and functioning, and that additional psychiatric comorbidity in schizophrenia would have similar adverse effects on QOL as substance use comorbidity.

METHODS

Participants with schizophrenia in the NIMH-funded Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) were classified using baseline diagnostic data into four groups: 1) monomorbid schizophrenia: 2) additional psychiatric comorbidity, 3) additional substance use comorbidity, and 4) both additional psychiatric and substance use comorbidity. Mixed models compared groups on self-reported QOL (SF-12 and Lehman QOLI) and rater-evaluated QOL (the Quality of Life Scale) using baseline, 6, 12 and 18-month follow-up data.

RESULTS

As hypothesized, patients with schizophrenia alone had a better QOL than those with any multimorbidity; patients with both psychiatric and substance use comorbidities had a worse QOL than those with fewer comorbidities; and patients with comorbid substance use alone were not significantly worse off than those with comorbid psychiatric disorder.

CONCLUSION

The multimorbidity framework more richly differentiates complex clinical presentations of schizophrenia than the current dual diagnosis concept and deserves further study as to its etiology, consequences, and treatment.

Optimizing medical care for geriatric patients in Austria: defining a top five list of "Choosing Wisely" recommendations using the Delphi technique

Purpose

Inappropriate use of diagnostic and therapeutic medical procedures is common and potentially harmful for older patients. The Austrian Society of Geriatrics and Gerontology defined a consensus of five recommendations to avoid overuse of medical interventions and to improve care of geriatric patients.

Methods

From an initial pool of 147 reliable recommendations, 20 were chosen by a structured selection process for inclusion in a Delphi process to define a list of five top recommendations for geriatric medicine. 12 experts in the field of geriatric medicine scored the recommendations in two Delphi rounds.

Results

The final five recommendations are concerning urinary catheters in elderly patients, percutaneous feeding tubes in patients with advanced dementia, antipsychotics as the first choice to treat behavioral and psychological symptoms of dementia, and screening for breast, colorectal, prostate, or lung cancer, and the use of antimicrobials to treat asymptomatic bacteriuria.

Conclusions

The selected recommendations have the potential to improve medical care for older patients, to reduce side effects caused by unnecessary medical procedures, and to save costs in the health care system.

Safety work and risk management as burdens of treatment in primary care: insights from a focused ethnographic study of patients with multimorbidity

Background

In primary health care, patient safety failures can arise in service access, doctor-patient relationships, communication between care providers, relational and management continuity, or technical procedures. Through the lens of multimorbidty, and using qualitative ethnographic methods, our study aimed to illuminate safety issues in primary care.

Methods

Data were triangulated from electronic health records (EHRs); observation of primary care consultations; annual interviews with patients, (informal) care providers and GPs. A thematic analysis of observation, interview and field note material sought to describe the patient safety issues encountered and any associated factors or processes. A more detailed longitudinal description of 6 cases was used to contextualise safety issues identified in observation, interviews and EHRs.

Results

Twenty-six patients were recruited. Events which could lead to harm were found in all areas of a framework based on published literature. “Under” and “over” consultation as a precursor of safety failures emerged through thematic analysis of observation and interview material. Other findings concerned workload (for doctors and patients) and the limitations of short consultation times. There were differences in health data collected directly from the patients versus that found in EHRs. Examples included reference to a stroke history and diagnoses for CKD and hypertension. Case study analysis revealed specific issues which appeared contextual to safety concerns, mostly around the management of polypharmacy and patient medication adherence. Clinical imperatives appear around risk management, but the study findings point to a potential conflict with patient expectations around investigation, diagnosis and treatment.

Discussion

Patient safety work involves further burdens on top of existing workload for both clinicians and patients. In this conceptualisation, safety work seemingly forms part of a negative feedback loop with patient safety itself. A line of argument drawn from the triangulation of findings from different sources, points to a tension between the desirability of a minimally disruptive medicine versus safety risks possibly associated with ‘under’ or ‘over’ consultation. Multimorbidity acts as a magnifier of tensions in the delivery of health services and quality care in general practice. More attention should be put on system design than patient or professional behaviour.

Key factors to consider when measuring multimorbidity: Results from an expert panel and online survey

Background:

There are multiple multimorbidity measures but little consensus on which measures are most appropriate for different circumstances.

Objective:

To share insights gained from discussions with experts in the fields of ageing research and multimorbidity on key factors to consider when measuring multimorbidity.

Design:

Descriptive study of expert opinions on multimorbidity measures, informed by literature to identify available measures followed by a face-to-face meeting and an online survey.

Results:

The expert group included clinicians, researchers and policymakers in Canada with expertise in the fields of multimorbidity and ageing. Of the 30 experts invited, 15 (50%) attended the in-person meeting and 14 (47%) responded to the subsequent online survey. Experts agreed that there is no single multimorbidity measure that is suitable for all research studies. They cited a number of factors that need to be considered in selecting a measure for use in a research study including: (1) fit with the study purpose; (2) the conditions included in multimorbidity measures; (3) the role of episodic conditions or diseases; and (4) the role of social factors and other concepts missing in existing approaches.

Conclusions:

The suitability of existing multimorbidity measures for use in a specific research study depends on factors such as the purpose of the study, outcomes examined and preferences of the involved stakeholders. The results of this study suggest that there are areas that require further building out in both the conceptualization and measurement of multimorbidity for the benefit of future clinical, research and policy decisions.

Can Wii Balance? Evaluating a Stepping Game for Older Adults

Decline in balance control is an issue for older adults as it leads to an increased risk of falling which may result in serious injury. Mitigating this risk may be achieved through balance training and exercise, but lack of adherence to an exercise program often occurs. Improvement in balance control may be difficult to quantify in an unbiased manner given the therapist providing the treatment also assesses the patient. We developed a gamified system using an off-the-shelf technology through an iterative feedback with therapists and clients to evaluate a response time during stepping as a measure of balance control. The game was designed using serious game strategies to increase participant engagement. This game included two Nintendo Wii balance boards between which the individual was required to step while the times were recorded. To provide evidence that the system could be used in a clinical environment, we conducted a cross-sectional study collecting data for five minutes at the beginning of a physiotherapy assessment. One hundred and four individuals older than 50 years of age were recruited who were able to step forward with or without an aid. The response time for a step using the system was negatively correlated to the Berg balance score.

Protocol for a program of research from the Aging, Community and Health Research Unit: Promoting optimal aging at home for older adults with multimorbidity

Background:

The goal of the Aging, Community and Health Research Unit (ACHRU) is to promote optimal aging at home for older adults with multimorbidity (≥2 chronic conditions) and to support their family/friend caregivers. This protocol paper reports the rationale and plan for this patient-oriented, cross-jurisdictional research program.

Objectives:

The objectives of the ACHRU research program are (i) to codesign integrated and person-centered interventions with older adults, family/friend caregivers, and providers; (ii) to examine the feasibility of newly designed interventions; (iii) to determine the intervention effectiveness on Triple Aim outcomes: health, patient/caregiver experience, and cost; (iv) to examine intervention context and implementation barriers and facilitators; (v) to use diverse integrated knowledge translation (IKT) strategies to engage knowledge users to support scalability and sustainability of effective interventions; and (vi) to build patient-oriented research capacity.

Design:

The research program was informed by the Knowledge-to-Action Framework and the Complexity Model. Six individual studies were conceptualized as integrated pieces of work. The results of the three initial descriptive studies will inform and be followed by three pragmatic randomized controlled trials. IKT and capacity building activities will be embedded in all six studies and tailored to the unique focus of each study.

Conclusions:

This research program will inform the development of effective and scalable person-centered interventions that are sustainable through interagency and intersectoral partnerships with community-based agencies, policy makers, and other health and social service agencies. Implementation of these interventions has the potential to transform health-care services and systems and improve the quality of life for older adults with multimorbidity and their caregivers.

Trial registration:

NCT02428387 (study 4), NCT02158741 (study 5), and NCT02209285 (study 6).

Towards incentivising integration: A typology of payments for integrated care

Traditional provider payment mechanisms may not create appropriate incentives for integrating care. Alternative payment mechanisms, such as bundled payments, have been introduced without uniform definitions, and existing payment typologies are not suitable for describing them. We use a systematic review combined with example integrated care programmes identified from practice in the Horizon2020 SELFIE project to inform a new typology of payment mechanisms for integrated care. The typology describes payments in terms of the scope of payment (Target population, Time, Sectors), the participation of providers (Provider coverage, Financial pooling/sharing), and the single provider/patient involvement (Income, Multiple disease/needs focus, and Quality measurement). There is a gap between rhetoric on the need for new payment mechanisms and those implemented in practice. Current payments for integrated care are mostly sector- and disease-specific, with questionable impact on those with the most need for integrated care. The typology provides a basis to improve financial incentives supporting more effective and efficient integrated care systems.

Using information communication technology in models of integrated community-based primary health care: learning from the iCOACH case studies

BACKGROUND

Information communication technology (ICT) is a critical enabler of integrated models of community-based primary health care; however, little is known about how existing technologies have been used to support new models of integrated care. To address this gap, we draw on data from an international study of integrated models, exploring how ICT is used to support activities of integrated care and the organizational and environmental barriers and enablers to its adoption.

METHODS

We take an embedded comparative multiple-case study approach using data from a study of implementation of nine models of integrated community-based primary health care, the Implementing Integrated Care for Older Adults with Complex Health Needs (iCOACH) study. Six cases from Canada, three each in Ontario and Quebec, and three in New Zealand, were studied. As part of the case studies, interviews were conducted with managers and front-line health care providers from February 2015 to March 2017. A qualitative descriptive approach was used to code data from 137 interviews and generate word tables to guide analysis.

RESULTS

Despite different models and contexts, we found strikingly similar accounts of the types of activities supported through ICT systems in each of the cases. ICT systems were used most frequently to support activities like care coordination by inter-professional teams through information sharing. However, providers were limited in their ability to efficiently share patient data due to data access issues across organizational and professional boundaries and due to system functionality limitations, such as a lack of interoperability.

CONCLUSIONS

Even in innovative models of care, managers and providers in our cases mainly use technology to enable traditional ways of working. Technology limitations prevent more innovative uses of technology that could support disruption necessary to improve care delivery. We argue the barriers to more innovative use of technology are linked to three factors: (1) information access barriers, (2) limited functionality of available technology, and (3) organizational and provider inertia.

Multiple chronic conditions: Implications for cognition - Findings from the Wisconsin Registry for Alzheimer's Prevention (WRAP)

INTRODUCTION

Several chronic illnesses have demonstrated relationships to cognitive decline in the context of aging. However, researchers have largely ignored the effects of multi-morbidity in the context of Alzheimer's disease and related dementias (ADRD) risk. The purpose of this study is to examine the relationship between multiple chronic conditions (MCC) and cognitive decline.

METHODS

Latent class analysis (LCA) was completed to identify different subgroups of the 1285 participants from the Wisconsin Registry for Alzheimer's Prevention who were recognized based on their self-reported chronic illnesses. Differences between variables of interest (i.e., biomarkers and depressive symptom scores) and each of the individual classes were then explored. Chi-square tests were used to examine the association between MCC and cognitive status.

RESULTS

LCA revealed a four-class model best fit solution. Participants in the sleep class had the highest incidence of new onset cognitive decline.

DISCUSSION

Findings offer evidence of an association between specific MCC groups and the development of cognitive decline. Nurses should monitor and screen for cognitive decline in the presence of MCC in order to better target self-management interventions.

Is telephone health coaching a useful population health strategy for supporting older people with multimorbidity? An evaluation of reach, effectiveness and cost-effectiveness using a 'trial within a cohort'

BACKGROUND

Innovative ways of delivering care are needed to improve outcomes for older people with multimorbidity. Health coaching involves 'a regular series of phone calls between patient and health professional to provide support and encouragement to promote healthy behaviours'. This intervention is promising, but evidence is insufficient to support a wider role in multimorbidity care. We evaluated health coaching in older people with multimorbidity.

METHODS

We used the innovative 'Trials within Cohorts' design. A cohort was recruited, and a trial was conducted using a 'patient-centred' consent model. A randomly selected group within the cohort were offered the intervention and were analysed as the intervention group whether they accepted the offer or not. The intervention sought to improve the skills of patients with multimorbidity to deal with a range of long-term conditions, through health coaching, social prescribing and low-intensity support for low mood.

RESULTS

We recruited 4377 older people, and 1306 met the eligibility criteria (two or more long-term conditions and moderate 'patient activation'). We selected 504 for health coaching, and 41% consented. More than 80% of consenters received the defined 'dose' of 4+ sessions. In an intention-to-treat analysis, those selected for health coaching did not improve on any outcome (patient activation, quality of life, depression or self-care) compared to usual care. We examined health care utilisation using hospital administrative and self-report data. Patients selected for health coaching demonstrated lower levels of emergency care use, but an increase in the use of planned services and higher overall costs, as well as a quality-adjusted life year (QALY) gain. The incremental cost per QALY was £8049, with a 70-79% probability of being cost-effective at conventional levels of willingness to pay.

CONCLUSIONS

Health coaching did not lead to significant benefits on the primary measures of patient-reported outcome. This is likely related to relatively low levels of uptake amongst those selected for the intervention. Demonstrating effectiveness in this design is challenging, as it estimates the effect of being selected for treatment, regardless of whether treatment is adopted. We argue that the treatment effect estimated is appropriate for health coaching, a proactive model relevant to many patients in the community, not just those seeking care.

TRIAL REGISTRATION

International Standard Randomised Controlled Trial Number ( ISRCTN12286422 ).

Reserve-building activities attenuate treatment burden in chronic illness: The mediating role of appraisal and social support

This study examines the importance of four psychosocial factors—personality, cognitive appraisal of quality of life, social support, and current reserve-building—in predicting treatment burden in chronically ill patients. Chronically ill patients (n = 446) completed web-based measures. Structural equation modeling was used to investigate psychosocial factors predicting treatment burden. Reserve-building activities indirectly reduced treatment burden by: (1) reducing health worries appraisals, (2) reducing financial difficulties, (3) increasing calm and peaceful appraisals, and (4) increasing perceived social support. These findings point to key behaviors that chronically ill people can use to attenuate their treatment burden.

Medication burden attributable to chronic co-morbid conditions in the very old and vulnerable

OBJECTIVE

Polypharmacy is common in older patients but relationships between polypharmacy and common co-morbid conditions have not been elucidated. Our goal was to determine relationships between daily oral medication use and common co-morbid disease dyads and triads using comprehensive medication and diagnostic data from a national sample of nursing homes (NH).

DESIGN

Retrospective, cross-sectional study.

SETTING

Nationally representative sample of U.S. Nursing Homes.

PARTICIPANTS

Nationally representative sample of long-term stay residents (n = 11734, 75% women) aged 65 years or older.

MEASUREMENTS

Diagnosis and medication data were analyzed. Proportion of daily oral medication intake attributed to treatment of common two-(dyads) and three-disease (triad) combinations and "health maintenance" agents (vitamins, dietary supplements, stool softeners without related diagnoses) was determined.

RESULTS

Older NH residents received slightly >8 oral medications/day with the number related to number of medical diagnoses (p < .0001). One third of chronic oral medication intake/day (excluding health maintenance agents) could be attributed to dyad combinations and about half to triad combinations despite an average of 5 other diagnoses. Triads were comprised of hypertension +/- arthritis +/- vascular disease, +/-depression, +/- osteoporosis +/- gastroesophageal reflux disease and +/- diabetes. Health maintenance agents accounted for 15-17% of daily oral medication intake (1.4 medications) such that almost two-thirds of daily oral medications were attributable to disease triads plus health maintenance. Fewer medications were prescribed for NH residents over age 85 (decreased ACE inhibitor and HMG CoA reductase inhibitor USE (p < .001)) while use of Alzheimer medications was higher (p < .01).

CONCLUSIONS

A large fraction of daily oral medications were attributed to management of common co-morbid disease dyads and triads. Efforts to reduce polypharmacy and unwanted medication interactions could focus on regimens for common co-morbid dyads and triads in varying populations.

Patterns and temporal trends of comorbidity among adult patients with incident cardiovascular disease in the UK between 2000 and 2014: A population-based cohort study

BACKGROUND

Multimorbidity in people with cardiovascular disease (CVD) is common, but large-scale contemporary reports of patterns and trends in patients with incident CVD are limited. We investigated the burden of comorbidities in patients with incident CVD, how it changed between 2000 and 2014, and how it varied by age, sex, and socioeconomic status (SES).

METHODS AND FINDINGS

We used the UK Clinical Practice Research Datalink with linkage to Hospital Episode Statistics, a population-based dataset from 674 UK general practices covering approximately 7% of the current UK population. We estimated crude and age/sex-standardised (to the 2013 European Standard Population) prevalence and 95% confidence intervals for 56 major comorbidities in individuals with incident non-fatal CVD. We further assessed temporal trends and patterns by age, sex, and SES groups, between 2000 and 2014. Among a total of 4,198,039 people aged 16 to 113 years, 229,205 incident cases of non-fatal CVD, defined as first diagnosis of ischaemic heart disease, stroke, or transient ischaemic attack, were identified. Although the age/sex-standardised incidence of CVD decreased by 34% between 2000 to 2014, the proportion of CVD patients with higher numbers of comorbidities increased. The prevalence of having 5 or more comorbidities increased 4-fold, rising from 6.3% (95% CI 5.6%-17.0%) in 2000 to 24.3% (22.1%-34.8%) in 2014 in age/sex-standardised models. The most common comorbidities in age/sex-standardised models were hypertension (28.9% [95% CI 27.7%-31.4%]), depression (23.0% [21.3%-26.0%]), arthritis (20.9% [19.5%-23.5%]), asthma (17.7% [15.8%-20.8%]), and anxiety (15.0% [13.7%-17.6%]). Cardiometabolic conditions and arthritis were highly prevalent among patients aged over 40 years, and mental illnesses were highly prevalent in patients aged 30-59 years. The age-standardised prevalence of having 5 or more comorbidities was 19.1% (95% CI 17.2%-22.7%) in women and 12.5% (12.0%-13.9%) in men, and women had twice the age-standardised prevalence of depression (31.1% [28.3%-35.5%] versus 15.0% [14.3%-16.5%]) and anxiety (19.6% [17.6%-23.3%] versus 10.4% [9.8%-11.8%]). The prevalence of depression was 46% higher in the most deprived fifth of SES compared with the least deprived fifth (age/sex-standardised prevalence of 38.4% [31.2%-62.0%] versus 26.3% [23.1%-34.5%], respectively). This is a descriptive study of routine electronic health records in the UK, which might underestimate the true prevalence of diseases.

CONCLUSIONS

The burden of multimorbidity and comorbidity in patients with incident non-fatal CVD increased between 2000 and 2014. On average, older patients, women, and socioeconomically deprived groups had higher numbers of comorbidities, but the type of comorbidities varied by age and sex. Cardiometabolic conditions contributed substantially to the burden, but 4 out of the 10 top comorbidities were non-cardiometabolic. The current single-disease paradigm in CVD management needs to broaden and incorporate the large and increasing burden of comorbidities.

Differences in health literacy profiles of patients admitted to a public and a private hospital in Melbourne, Australia

BACKGROUND

Health literacy refers to an individual's ability to find, understand and use health information in order to promote and maintain health. An individual's health literacy may also be influenced by the way health care organisations deliver care. The aim of this study was to investigate the influence of hospital service type (public versus private) on individual health literacy.

METHODS

Two cross-sectional surveys were conducted using the Health Literacy Questionnaire (HLQ), a multi-dimensional self-report instrument covering nine health literacy domains. Recently discharged private patients (n = 3121) were sent the survey in English, public patients (n = 384) were sent the survey in English, Arabic, Chinese, Vietnamese, Italian or Greek. Eligibility included hospitalisation ≥24 h in last 30 days, aged ≥18 years, no cognitive impairment. Odds ratios were used to assess differences between hospital sociodemographic and health related variables. ANOVA and Cohen's effect sizes compared HLQ scores between hospitals. Chi square and multiple logistic regression were used to determine whether differences between private and public hospital HLQ scores was independent of hospital population sociodemographic differences. ANOVA was used to review associations between HLQ scores and subgroups of demographic, health behaviour and health conditions and these were then compared across the two hospital populations.

RESULTS

Public hospital participants scored lower than private hospital participants on eight of the nine health literacy domains of the HLQ (scores for Active Appraisal did not differ between the two samples). Six domains, five of which in part measure the impact of how care is delivered on health literacy, remained lower among public hospital participants after controlling for age, education, language and income. Across both hospital populations, participants who were smokers, those who had low physical activity, those with depression and/or anxiety and those with 3 or more chronic conditions reported lower scores on some HLQ domains.

CONCLUSIONS

Our finding of lower health literacy among patients who had received care at a public hospital in comparison to a private hospital, even after adjustment for sociodemographic and language differences, suggests that private hospitals may possess organisational attributes (environment, structure, values, practices and/or workforce competencies) that result in improved health literacy responsiveness.

Long-acting intramuscular naltrexone for opioid use disorder: Utilization and association with multi-morbidity nationally in the Veterans Health Administration

BACKGROUND

Long acting intramuscular (IM) naltrexone is an effective treatment for opioid use disorder (OUD), but rates and correlates of its use have not been studied.

METHODS

National administrative from the Veterans Health Administration (VHA) from Fiscal Year 2012 identified only 16 VHA facilities that prescribed IM naltrexone to 5 or more veterans diagnosed with OUD. Data from these facilities were used to identify sociodemographic, diagnostic, and service use characteristics, including use of psychotropic medication, that were characteristic of veterans who filled prescriptions for IM naltrexone. This was in comparison to users of opiate agonist treatments (methadone or buprenorphine) or veterans with no pharmacologic treatment for OUD. Comparisons were made using both bi-variate analyses and multivariable logistic regression.

RESULTS

Only 179 of 16,402 veterans with OUD (1%) at these 16 facilities filled a prescription for IM naltrexone and only 256 of 99,394 (0.26%) nationally. These veterans were characterized by past homelessness, co-morbid alcohol use disorder, multiple psychiatric disorders, and a greater likelihood of psychiatric hospitalization, as well as mental health outpatient and antidepressant medication use.

CONCLUSIONS

IM naltrexone is rarely used for OUD and is primarily used for patients with multiple co-morbidities, especially alcohol use disorder and serious mental illness. The use of this treatment illustrates many of the principles identified by the emerging focus on multi-morbidity as a critical feature of clinical practice.

Mapping of global scientific research in comorbidity and multimorbidity: A cross-sectional analysis

BACKGROUND

The management of comorbidity and multimorbidity poses major challenges to health services around the world. Analysis of scientific research in comorbidity and multimorbidity is limited in the biomedical literature. This study aimed to map global scientific research in comorbidity and multimorbidity to understand the maturity and growth of the area during the past decades.

METHODS AND FINDINGS

This was a cross-sectional analysis of the Web of Science. Searches were run from inception until November 8, 2016. We included research articles or reviews with no restrictions by language or publication date. Data abstraction was done by one researcher. A process of standardization was conducted by two researchers to unify different terms and grammatical variants and to remove typographical, transcription, and/or indexing errors. All potential discrepancies were resolved via discussion. Descriptive analyses were conducted (including the number of papers, citations, signatures, most prolific authors, countries, journals and keywords). Network analyses of collaborations between countries and co-words were presented. During the period 1970-2016, 85994 papers (64.0% in 2010-2016) were published in 3500 journals. There was wide diversity in the specialty of the journals, with psychiatry (16558 papers; 19.3%), surgery (9570 papers; 11.1%), clinical neurology (9275 papers; 10.8%), and general and internal medicine (7622 papers; 8.9%) the most common. PLOS One (1223 papers; 1.4%), the Journal of Affective Disorders (1154 papers; 1.3%), the Journal of Clinical Psychiatry (727 papers; 0.8%), the Journal of the American Geriatrics Society (634 papers; 0.7%) and Obesity Surgery (588 papers; 0.7%) published the largest number of papers. 168 countries were involved in the production of papers. The global productivity ranking was headed by the United States (37624 papers), followed by the United Kingdom (7355 papers), Germany (6899 papers) and Canada (5706 papers). Twenty authors who published 100 or more papers were identified; the most prolific authors were affiliated with Harvard Medical School, State University of New York Upstate Medical University, National Taiwan Normal University and China Medical University. The 50 most cited papers ("citation classics" with at least 1000 citations) were published in 20 journals, led by JAMA Psychiatry (11 papers) and JAMA (10 papers). The most cited papers provided contributions focusing on methodological aspects (e.g. Charlson Comorbidity Index, Elixhauser Comorbidity Index, APACHE prognostic system), but also important studies on chronic diseases (e.g. epidemiology of mental disorders and its correlates by the U.S. National Comorbidity Survey, Fried's frailty phenotype or the management of obesity).

CONCLUSIONS

Ours is the first analysis of global scientific research in comorbidity and multimorbidity. Scientific production in the field is increasing worldwide with research leadership of Western countries, most notably, the United States.

The Associations of Multimorbidity With Health-Related Productivity Loss in a Large and Diverse Public Sector Setting: A Cross-Sectional Survey

OBJECTIVE

To evaluate absenteeism, presenteeism, and total lost productive time (LPT) associated with multimorbidity.

METHODS

Cross-sectional data from 3228 state-government employees from Tasmania were collected in 2013. The validated measures of absenteeism, presenteeism, and LPT were obtained from employees' self-reported data over a 28-day period. Analyses were stratified by sex. Negative binomial models were used to estimate the associations between multimorbidity and LPT.

RESULTS

The average health-related total LPT was 1.2 (standard deviation [SD] = 2.4) and 1.7 (SD = 3.5) days for men and women with multimorbidity, respectively. Women (rate ratio [RR] = 2.9, 95% confidence interval [CI] 1.8 to 4.9) and men (RR = 4.4, 95%CI 3.0 to 6.2) with 4+ chronic conditions were significantly more likely to report LPT compared with those without any chronic conditions.

CONCLUSION

We found multimorbidity is of concern within the workforce, with a positive association of multimorbidity and LPT observed, and significant differences in LPT between men and women reporting multimorbidity.

Quality of care for people with multimorbidity - a case series

Background

Multimorbidity is becoming increasingly prevalent and presents challenges for healthcare providers and systems. Studies examining the relationship between multimorbidity and quality of care report mixed findings. The purpose of this study was to investigate quality of care for people with multimorbidity in the publicly funded healthcare system in Denmark.

Methods

To investigate the quality of care for people with multimorbidity different groups of clinicians from the hospital, general practice and the municipality reviewed records from 23 persons with multimorbidity and discussed them in three focus groups. Before each focus group, clinicians were asked to review patients’ medical records and assess their care by responding to a questionnaire. Medical records from 2013 from hospitals, general practice, and health centers in the local municipality were collected and linked for the 23 patients. Further, two clinical pharmacologists reviewed the appropriateness of medications listed in patient records.

Results

The review of the patients’ records conducted by three groups of clinicians revealed that around half of the patients received adequate care for the single condition which prompted the episode of care such as a hospitalization, a visit to an outpatient clinic or the general practitioner. Further, the care provided to approximately two-thirds of the patients did not take comorbidities into account and insufficiently addressed more diffuse symptoms or problems. The review of the medication lists revealed that the majority of the medication lists contained inappropriate medications and that there were incongruity in medication listed in the primary and secondary care sector. Several barriers for providing high quality care were identified. These included relative short consultation times in general practice and outpatient clinics, lack of care coordinators, and lack of shared IT-system proving an overview of the treatment.

Conclusions

Our findings reveal quality of care deficiencies for people with multimorbidity. Suggestions for care improvement for people with multimorbidity includes formally assigned responsibility for care coordination, a change in the financial incentive structure towards a system rewarding high quality care and care focusing on prevention of disease exacerbation, as well as implementing shared medical record systems.

Epidemiology of Multimorbidity in Older Adults with Cardiovascular Disease

Multimorbidity is the most significant condition affecting older adults, and it impacts every component of health care management and delivery. Multimorbidity significantly increases with age. For individuals with a diagnosis of cardiovascular disease, multimorbidity has a significant effect on the presentation of the disease and the diagnosis, management, and patient-centered preferences in care. Evidence-based therapeutics have focused on cardiovascular focused morbidity. Over the next 25 years, the proportion of adults aged 65 and older is estimated to increase three-fold. The needs of these patients require a fundamental shift in care from single disease practices to a more patient-centered framework.

Multimorbidity and depression: A systematic review and meta-analysis

BACKGROUND

Multimorbidity, the presence of two or more chronic conditions, is increasingly common and complicates the assessment and management of depression. The aim was to investigate the relationship between multimorbidity and depression.

METHOD

A systematic literature search was conducted using the databases; PsychINFO, Medline, Embase, CINAHL and Cochrane Central. Results were meta-analysed to determine risk for a depressive disorder or depressive symptoms in people with multimorbidity.

RESULTS

Forty articles were identified as eligible (n = 381527). The risk for depressive disorder was twice as great for people with multimorbidity compared to those without multimorbidity [RR: 2.13 (95% CI 1.62-2.80) p<0.001] and three times greater for people with multimorbidity compared to those without any chronic physical condition [RR: 2.97 (95% CI 2.06-4.27) p<0.001]. There was a 45% greater odds of having a depressive disorder with each additional chronic condition compared to the odds of having a depressive disorder with no chronic physical condition [OR: 1.45 (95% CI 1.28-1.64) p<0.001]. A significant but weak association was found between the number of chronic conditions and depressive symptoms [r = 0.26 (95% CI 0.18-0.33) p <0.001].

LIMITATIONS

Although valid measures of depression were used in these studies, the majority assessed the presence or absence of multimorbidity by self-report measures.

CONCLUSIONS

Depression is two to three times more likely in people with multimorbidity compared to people without multimorbidity or those who have no chronic physical condition. Greater knowledge of this risk supports identification and management of depression.

Relevant models and elements of integrated care for multi-morbidity: Results of a scoping review

BACKGROUND

In order to provide adequate care for the growing group of persons with multi-morbidity, innovative integrated care programmes are appearing. The aims of the current scoping review were to i) identify relevant models and elements of integrated care for multi-morbidity and ii) to subsequently identify which of these models and elements are applied in integrated care programmes for multi-morbidity.

METHODS

A scoping review was conducted in the following scientific databases: Cochrane, Embase, PubMed, PsycInfo, Scopus, Sociological Abstracts, Social Services Abstracts, and Web of Science. A search strategy encompassing a) models, elements and programmes, b) integrated care, and c) multi-morbidity was used to identify both models and elements (aim 1) and implemented programmes of integrated care for multi-morbidity (aim 2). Data extraction was done by two independent reviewers. Besides general information on publications (e.g. publication year, geographical region, study design, and target group), data was extracted on models and elements that publications refer to, as well as which models and elements are applied in recently implemented programmes in the EU and US.

RESULTS

In the review 11,641 articles were identified. After title and abstract screening, 272 articles remained. Full text screening resulted in the inclusion of 92 articles on models and elements, and 50 articles on programmes, of which 16 were unique programmes in the EU (n=11) and US (n=5). Wagner's Chronic Care Model (CCM) and the Guided Care Model (GCM) were most often referred to (CCM n=31; GCM n=6); the majority of the other models found were only referred to once (aim 1). Both the CCM and GCM focus on integrated care in general and do not explicitly focus on multi-morbidity. Identified elements of integrated care were clustered according to the WHO health system building blocks. Most elements pertained to 'service delivery'. Across all components, the five elements referred to most often are person-centred care, holistic or needs assessment, integration and coordination of care services and/or professionals, collaboration, and self-management (aim 1). Most (n=10) of the 16 identified implemented programmes for multi-morbidity referred to the CCM (aim 2). Of all identified programmes, the elements most often included were self-management, comprehensive assessment, interdisciplinary care or collaboration, person-centred care and electronic information system (aim 2).

CONCLUSION

Most models and elements found in the literature focus on integrated care in general and do not explicitly focus on multi-morbidity. In line with this, most programmes identified in the literature build on the CCM. A comprehensive framework that better accounts for the complexities resulting from multi-morbidity is needed.

Multimorbidity associated with polypharmacy and negative self-perception of health

Abstract Objective: to verify the association between the multimorbidity of the elderly and sociodemographic variables, self-perception of health and polypharmacy. Method: a cross-sectional study was performed. The research data was collected using the Health, Well-Being and Aging questionnaire. The sample was composed of 676 people aged 60 years or more, who were residents of small towns in the north of the state of Rio Grande do Sul, Brazil. The dependent variable was multimorbidity, that is, the occurrence of two or more chronic non-communicable diseases in the same person. The independent variables were demographic, socioeconomic and health-related characteristics. Poisson’s raw and robust regression model was used to analyze the effect of the independent variables in relation to the outcome and p was considered significant when <0.05. Result: among the elderly interviewed, 45% presented multimorbidity, 51.1% reported a self-perception of poor/very poor health and 37.1% used polypharmacy. After the analysis was adjusted to the occurrence of multimorbidity, association with the following variables was found: health perception (regular/poor/very poor) PR=1.15 (CI95%; 1.09 - 1.22) and use of polypharmacy PR=1.29 (CI95%; 1.22 - 1.35). Conclusion: Multimorbidity may interfere negatively in the self-perception of health of the elderly contributing to increased medicine consumption.

Addressing the Evidence Gap in Stroke Rehabilitation for Complex Patients: A Preliminary Research Agenda

Evidence suggests that a stroke occurs in isolation (no comorbid conditions) in less than 6% of patients. Multimorbidity, compounded by psychosocial issues, makes treatment and recovery for stroke increasingly complex. Recent research and health policy documents called for a better understanding of the needs of this patient population, and for the development and testing of models of care that meet their needs. A research agenda specific to complexity is required. The primary objective of the think tank was to identify and prioritize research questions that meet the information needs of stakeholders, and to develop a research agenda specific to stroke rehabilitation and patient complexity. A modified Delphi and World Café approach underpinned the think tank meeting, approaches well recognized to foster interaction, dialogue, and collaboration between stakeholders. Forty-three researchers, clinicians, and policymakers attended a 2-day meeting. Initial question-generating activities resulted in 120 potential research questions. Sixteen high-priority research questions were identified, focusing on predetermined complexity characteristics-multimorbidity, social determinants, patient characteristics, social supports, and system factors. The final questions are presented as a prioritized research framework. An emergent result of this activity is the development of a complexity and stroke rehabilitation research network. The research agenda reflects topics of importance to stakeholders working with stroke patients with increasingly complex care needs. This robust process resulted in a preliminary research agenda that could provide policymakers with the evidence needed to make improvements toward better-organized services, better coordination between settings, improved patient outcomes, and lower system costs.

Computer technologies to integrate medical treatments to manage multimorbidity

The high prevalence of multimorbid cases is a challenge for Health-Care Systems today. Clinical practice guidelines are the means to register and transmit the available evidence-based medical knowledge concerning concrete diseases. Several computer languages have been defined to represent this knowledge in a way that computers could use to help physicians in the daily practice of medicine. The generation of guidelines for all possible multimorbidities entails several issues that are difficult to address. Consequently, numerous medical informatics technologies have appeared merging computer information structures in a way that the treatment knowledge about single diseases could be combined in order to deliver health-care to patients suffering from multimorbidity. This paper proposes a classification of the most promising current technologies addressing this issue and provides an analysis of their maturity, strengths, and weaknesses. We conclude with an enumeration of ten relevant issues to consider when developing such technologies.

Serious Psychological Distress and Emergency Room Use among Adults with Multimorbidity in the United States

OBJECTIVES

(1) To examine the association between serious psychological distress (SPD) and emergency room (ER) use in the past 12 months among adults with multimorbidity in the United States (US) and (2) to investigate the association between SPD and the reasons for ER use.

METHODS

The current study used a cross-sectional design with retrospective data from the 2015 National Health Interview Survey. Logistic regression models were used to assess the association between SPD and ER use among adults with multimorbidity. Among ER users, adjusted logistic regression models were conducted to examine the association between SPD and the reasons for the ER use.

RESULTS

After controlling for other variables, adults with multimorbidity and SPD were more likely to use ER than those with multimorbidity and no SPD (AOR = 1.61, 95% CI = 1.26, 2.04). Among ER users, there were no significant associations between SPD and the reasons for ER use after controlling for other variables.

CONCLUSION

Adults with multimorbidity and SPD were more likely to use ER as compared to those with multimorbidity and no SPD. Among adults with multimorbidity, routine screening for SPD may be needed to reduce the ER use.

The Patient-Centered Care and Receipt of Preventive Services Among Older Adults With Chronic Diseases: A Nationwide Cross-sectional Study

This article investigates the associations between the patient-centered care (PCC) and receipt of preventive services among older adults with chronic diseases. Data were derived from the nationally representative Medical Expenditure Panel Survey. The full-year consolidated data files from 2009 to 2013 were pooled to yield a final analytic sample (N = 16 654). Study outcomes included the receipt of 7 types of preventive screenings and 2 types of health education services. Patients’ PCC groups were categorized as PCC, partial PCC, and non-PCC, based on 9 questions classified under the 3 distinctive attributes of PCC—whole-person care, patient engagement, and enhanced access to care. Prevalence rates for each outcome variable were calculated. We estimated odds ratios from multiple logistic regressions, comparing the likelihood of outcome variables across 3 groups of patients. Adjusting for covariates, the PCC group was more likely than the non-PCC group to receive 8 types of preventive services. The partial PCC group had a greater likelihood than the non-PCC group of receiving 7 types of preventive services. Our study reveals significant associations between PCC and receipt of preventive services. PCC has demonstrated the potential to improve preventive care for older adults with chronic diseases.

The contribution of risk factors to socioeconomic inequalities in multimorbidity across the lifecourse: a longitudinal analysis of the Twenty-07 cohort

BACKGROUND

Multimorbidity is a major challenge to health systems globally and disproportionately affects socioeconomically disadvantaged populations. We examined socioeconomic inequalities in developing multimorbidity across the lifecourse and investigated the contribution of five behaviour-related risk factors.

METHODS

The Twenty-07 study recruited participants aged approximately 15, 35, and 55 years in 1987 and followed them up over 20 years. The primary outcome was development of multimorbidity (2+ health conditions). The relationship between five different risk factors (smoking, alcohol consumption, diet, body mass index (BMI), physical activity) and the development of multimorbidity was assessed. Social patterning in the development of multimorbidity based on two measures of socioeconomic status (area-based deprivation and household income) was then determined, followed by investigation of potential mediation by the five risk factors. Multilevel logistic regression models and predictive margins were used for statistical analyses. Socioeconomic inequalities in multimorbidity were quantified using relative indices of inequality and attenuation assessed through addition of risk factors.

RESULTS

Multimorbidity prevalence increased markedly in all cohorts over the 20 years. Socioeconomic disadvantage was associated with increased risk of developing multimorbidity (most vs least deprived areas: odds ratio (OR) 1.46, 95% confidence interval (CI) 1.26-1.68), and the risk was at least as great when assessed by income (OR 1.53, 95% CI 1.25-1.87) or when defining multimorbidity as 3+ conditions. Smoking (current vs never OR 1.56, 1.36-1.78), diet (no fruit/vegetable consumption in previous week vs consumption every day OR 1.57, 95% CI 1.33-1.84), and BMI (morbidly obese vs healthy weight OR 1.88, 95% CI 1.42-2.49) were strong independent predictors of developing multimorbidity. A dose-response relationship was observed with number of risk factors and subsequent multimorbidity (3+ risk factors vs none OR 1.91, 95% CI 1.57-2.33). However, the five risk factors combined explained only 40.8% of socioeconomic inequalities in multimorbidity development.

CONCLUSIONS

Preventive measures addressing known risk factors, particularly obesity and smoking, could reduce the future multimorbidity burden. However, major socioeconomic inequalities in the development of multimorbidity exist even after taking account of known risk factors. Tackling social determinants of health, including holistic health and social care, is necessary if the rising burden of multimorbidity in disadvantaged populations is to be redressed.

HIV and ageing: improving quantity and quality of life

PURPOSE OF REVIEW

Evidence-based strategies are needed to address the growing complexity of care of those ageing with HIV so that as life expectancy is extended, quality of life is also enhanced.

RECENT FINDINGS

Modifiable contributing factors to the quantity and quality of life in adults ageing with HIV include: burden of harmful health behaviours, injury from HIV infection, HIV treatment toxicity and general burden of age-associated comorbidities. In turn, these factors contribute to geriatric syndromes including multimorbidity and polypharmacy, physiologic frailty, falls and fragility fractures and cognitive dysfunction, which further compromise the quality of life long before they lead to mortality.

SUMMARY

Viral suppression of HIV with combination antiviral therapy has led to increasing longevity but has not enabled a complete return to health among ageing HIV-infected individuals (HIV+). As adults age with HIV, the role of HIV itself and associated inflammation, effects of exposure to antiretroviral agents, the high prevalence of modifiable risk factors for age-associated conditions (e.g. smoking), and the effects of other viral coinfections are all influencing the health trajectory of persons ageing with HIV. We must move from the simplistic notion of HIV becoming a 'chronic controllable illness' to understanding the continually evolving 'treated' history of HIV infection with the burden of age-associated conditions and geriatric syndromes in the context of an altered and ageing immune system.

GPs' perspectives on prescribing for older people in primary care: a qualitative study

AIMS

The aim of this study was firstly to reveal the determinants of GP prescribing behaviour for older adults in primary care and secondly to elicit GPs' views on the potential role for broad intervention strategies involving pharmacists and/or information technology systems in general practice.

METHODS

Semi-structured qualitative interviews were carried out with a purposive sample of GPs. Three multidisciplinary researchers independently coded the interview data using a framework approach. Emerging themes were mapped to the Theoretical Domains Framework (TDF), a tool used to apply behaviour change theories.

RESULTS

Sixteen GPs participated in the study. The following domains in the TDF were identified as being important determinants of GP prescribing behaviour: 'Knowledge', 'Skills', 'Reinforcement', 'Memory Attention and Decision Process', 'Environmental Context and Resources', 'Social Influences', 'Social/Professional Role and Identity'. Participants reported that the challenges associated with prescribing for an increasingly older population will require them to become more knowledgeable in pharmacology and drug interactions and they called for extra training in these topics. GPs viewed strategies such as academic detailing sessions delivered by pharmacists or information technology systems as having a positive role to play in optimizing prescribing.

CONCLUSION

This study highlights the complexities of behavioural determinants of prescribing for older people in primary care and the need for additional supports to optimize prescribing for this growing cohort of patients. Interventions that incorporate, but are not limited to interprofessional collaboration with pharmacists and information technology systems, were identified by GPs as being potentially useful for improving prescribing behaviour, and therefore require further exploration.

Optimizing health system response to patient's needs: an argument for the importance of functioning information

BACKGROUND

Current health systems are increasingly challenged to meet the needs of a growing number of patients living with chronic and often multiple health conditions. The primary outcome of care, it is argued, is not merely curing disease but also optimizing functioning over a person's life span. According to the World Health Organization, functioning can serve as foundation for a comprehensive picture of health and augment the biomedical perspective with a broader and more comprehensive picture of health as it plays out in people's lives. The crucial importance of information about patient's functioning for a well-performing health system, however, has yet to be sufficiently appreciated.

METHODS

This paper argues that functioning information is fundamental in all components of health systems and enhances the capacity of health systems to optimize patients' health and health-related needs.

RESULTS AND CONCLUSION

Beyond making sense of biomedical disease patterns, health systems can profit from using functioning information to improve interprofessional collaboration and achieve cross-cutting disease treatment outcomes. Implications for rehabilitation Functioning is a key health outcome for rehabilitation within health systems. Information on restoring, maintaining, and optimizing human functioning can strengthen health system response to patients' health and rehabilitative needs. Functioning information guides health systems to achieve cross-cutting health outcomes that respond to the needs of the growing number of individuals living with chronic and multiple health conditions. Accounting for individuals functioning helps to overcome fragmentation of care and to improve interprofessional collaboration across settings.

Adherence and healthcare utilization among older adults with COPD and depression

BACKGROUND AND OBJECTIVE

Adherence to chronic obstructive pulmonary disease (COPD) maintenance medications and antidepressants may reduce healthcare utilization among multimorbid individuals with COPD and depression. We quantified the independent effects of adherence to antidepressants and COPD maintenance medications on healthcare utilization among individuals co-diagnosed with COPD and depression.

PROCEDURES

We conducted a retrospective cohort study using a 2006-2012 5% random sample of Medicare beneficiaries co-diagnosed with COPD and depression who had two or more prescription fills of both COPD maintenance medications and antidepressants. We measured adherence to medications using the proportion of days covered per 30-day period. The primary outcomes were all-cause emergency department (ED) visits and hospitalizations. Beneficiaries were followed over a minimum 12-month follow-up period.

RESULTS

Of the 16,075 beneficiaries meeting inclusion criteria, 21% achieved adherence ≥80% to COPD maintenance medications and 55% achieved adherence ≥80% to antidepressants. Compared to no use and controlling for antidepressant adherence and potential confounders, higher (≥80%) levels of adherence to COPD maintenance medications were associated with decreased risk of ED visits (hazard ratio (HR) 0.79; 95% CI 0.74, 0.83) and hospitalizations (HR 0.82; 95% CI 0.78, 0.87). Similarly, higher levels (≥80%) of adherence to antidepressants resulted in decreased risk of ED visits (HR 0.74; 95% CI 0.70, 0.78) and hospitalizations (HR 0.77; 95% CI 0.73, 0.81) compared to no use.

CONCLUSIONS

Clinicians can assist in the improved management of their multimorbid patients' health by treating depression among patients with COPD and monitoring and encouraging adherence to the regimens they prescribe.

Management of long-term conditions and dementia: The role of the Admiral Nurse

As life expectancy increases so people often develop a range of conditions and disabilities in the years before death. Multimorbidity represents the most common 'disease pattern' found among the elderly and is characterised by complex interactions of co-existing diseases where a medical approach focused on a single disease does not suffice. People with dementia who also have other comorbidities do not always have their comorbid conditions managed as those without dementia which often lead to a high number of hospital admissions with longer lengths of stay and greater treatment costs. This case study presents the case management approach taken by Admiral Nursing in managing the complexities where there is comorbidity of a long-term condition and a diagnosis of dementia. By empowering the person and their carer with information and choices and through good case management and communication, people can be supported to live well and avoid inappropriate hospital admissions.

Profile of a national sample of Canadian children with participation and activity limitations

Little is known about the nature of Canadian children with participation or activity limitations. Our objective was to profile a nationally representative sample of Canadian children with report of participation or activity limitation including identifying the major medical reasons attributed to these limitations and describe their sociodemographic and functional characteristics. We used data from the Canadian 2006 Participation and Activity Limitation Survey, a post-census Statistics Canada national survey of adults and children whose everyday activities were limited because of a condition or health problem. Data were collected by telephone interview of children's (<15 years) parents. A sample of those who answered 'yes' to the 2006 Canada Census disability filter questions was chosen for follow-up. Functional ability was assessed using the Health Utility Index. Mental health (26.1%) was the most common reason reported for participation and activity limitations followed by respiratory (9.8%), neurological (5.5%), and congenital (4.6%) conditions. Having a comorbid condition was associated with each major reason for limitation. Mental health, neurological, and congenital conditions showed the highest risk of functional limitation. In conclusion, mental health conditions and those with multiple conditions should be a primary focus for interventions aimed at reducing the impact of health conditions.