Multimorbidity and quality of life: Systematic literature review and meta-analysis

Octodon degus: a natural model of multimorbidity for ageing research

Integrating the multifactorial processes co-occurring in both physiological and pathological human conditions still remains one of the main challenges in translational investigation. Moreover, the impact of age-associated disorders has increased, which underlines the urgent need to find a feasible model that could help in the development of successful therapies. In this sense, the Octodon degus has been indicated as a 'natural' model in many biomedical areas, especially in ageing. This rodent shows complex social interactions and high sensitiveness to early-stressful events, which have been used to investigate neurodevelopmental processes. Interestingly, a high genetic similarity with some key proteins implicated in human diseases, such as apolipoprotein-E, β-amyloid or insulin, has been demonstrated. On the other hand, the fact that this animal is diurnal has provided important contribution in the field of circadian biology. Concerning age-related diseases, this rodent could be a good model of multimorbidity since it naturally develops cognitive decline, neurodegenerative histopathological hallmarks, visual degeneration, type II diabetes, endocrinological and metabolic dysfunctions, neoplasias and kidneys alterations. In this review we have collected and summarized the studies performed on the Octodon degus through the years that support its use as a model for biomedical research, with a special focus on ageing.

Cross-sectional evaluation of the interaction between activity relative-time expenditure and comorbidity concerning physical quality of life

Quality of life (QoL) is a matter of concern in both healthy and diseased individuals. Lifestyle factors such as physical activity and sleep have a direct impact on QoL. In this context, interactions between activity time expenditure and QoL might be different in comorbid and non comorbid patients. Besides, the quantification and evaluation of time expenditure is ordinarily measured as the absolute time devoted to each activity. The objective of this study is the evaluation of the influence and interactions of activity-relative time expenditure and co-morbidity in Physical QoL.The study involved 302 consecutive patients, from an Internal Medicine ambulatory evaluation. Validated questionnaires were used to collect demographic variables and time expenditure variables. QoL was gathered with de survey short form-36questionnaire. Comorbidity was compiled with de Charlson Comorbidity Index. SPSS v20.0 was used for statistical analysis.As hypothesized, healthy subjects had higher Physical QoL score than comorbid subjects (P < .05). Physical activity and sleep relative time expenditure were statistically significant and associated to a better QoL in comorbid patients (P < .05). Interestingly, sleep was found to have statistically significant interaction with a score of ≥2 in the Charlson Comorbidity Index. Age, gender, comorbidity, physical activity relative time expenditure, and the interaction between relative time dedicated to sleep and comorbidity were found statistically significant in a multivariate model on Physical QoL prediction.Activity-relative time expenditure could be an adequate measure of daily activity pattern in the evaluation of QoL. Relative time spent in physical activity and sleep might be positively associated to Physical QoL. Sleep and comorbidity could have a statistically significant interaction in the prediction of Physical QoL.

Quality of life in patients with comorbid serious mental illness and chronic diseases: A structural equation model

AIMS

To investigate the factors affecting the quality of life among adults with comorbid serious mental illness and chronic diseases.

DESIGN

Descriptive, cross-sectional study design.

METHODS

In total, 204 patients with serious mental illness were recruited from two hospitals. Self-reported data were collected using the Brief Psychiatric Rating Scale, Internalised Stigma of Mental Illness, Patient Activation Measure and brief version of the World Health Organization Quality of Life Instrument. Data were collected between July 2018 - January 2019. The structural equation model was applied to examine the associations among the study variables.

RESULTS

Internalized stigma (β = -0.479, p = .002) had the greatest direct effect on quality of life, followed by patient activation (β = 0.238, p = .002), severity of comorbidities (β = -0.207, p = .002) and psychiatric symptoms (β = -0.186, p = .006). In addition, psychiatric symptoms directly influenced the severity of comorbidities, which in turn directly influenced internalized stigma and then in turn directly influenced patient activation and ultimately influenced quality of life.

CONCLUSION

The relationship between internalized stigma and quality of life is significantly mediated by patient activation. This finding provides a theoretical basis for developing patient activation interventions for patients with comorbid mental and chronic diseases, which potentially improve the quality of life of this population.

IMPACT

Multiple comorbidities cause impaired quality of life in patients with serious mental illnesses. We found that patient activation plays an important role in the management of chronic diseases for achieving more favourable quality of life, but this is negatively affected by internalized stigma. These findings can help mental health professionals develop tailored intervention strategies to enhance quality of life by promoting patient activation and reducing internalized stigma, psychiatric symptoms, and comorbidity severity in patients with comorbid serious mental illnesses and chronic diseases.

Impact of periodontitis on quality of life among subjects with rheumatoid arthritis: a cross sectional study

BACKGROUND

This study aimed to assess the impact of periodontitis (PD) on the health related quality of life (HRQoL) and oral health related QoL (OHRQoL) of subjects with rheumatoid arthritis (RA) and PD.

METHODS

Subjects from dental and RA clinics were screened. Complete periodontal examinations were performed. Subjects were divided into 4 groups: RA-PD, RA, PD and healthy controls (HC). Questionnaires on characteristics and Malaysian versions of Oral Health Impact Profile (OHIP-14(M)) and Health Assessment Questionnaire (HAQ-DI)) were answered.

RESULTS

A total of 187 subjects were included (29 RA-PD, 58 RA, 43 PD and 57 HC). OHIP-14(M) severity score was highest in the PD group (17.23 ± 10.36) but only significantly higher than the HC group (p < 0.05). The HAQ-DI scores of the RA group was significantly higher than the PD and HC groups (p < 0.05). The interaction between the effects of PD and RA on the OHRQoL and HRQoL was statistically significant (p < 0.05).

CONCLUSION

PD and RA subjects both suffer impacts on their OHRQoL and HRQoL respectively. The interaction effect of both diseases significantly conferred impacts on their OHRQoL and HRQoL as measured by the OHIP-14(M) and HAQ-DI.

Health-Related Quality of Life and Its Correlation With Depression Among Chinese Centenarians

Background: As evidence on depression and health-related quality of life (HRQoL) among the oldest-old is currently limited, this study aimed to re-examine the association between depression and HRQoL among centenarians.

Methods: We analyzed cross-sectional data from the China Hainan Centenarian Cohort Study (CHCCS). The 15-item Geriatric Depression Scale (GDS-15) and three-level EuroQol five-dimensions (EQ-5D-3L) were used to evaluate depression and HRQoL, respectively. Poor health states were defined as EQ-5D index <0.665. Based on their GDS-15 score, individuals were categorized into three stages of depression: major depressive disorder (MDD; score ≥10), minor depressive disorder (MnDD; score between 6 and 9), and normal (score ≤ 5). Based on sex and comorbidity stratification, multivariable logistic regression was used to calculate the risk of poor health state in different levels of depression. We also used restricted cubic splines with a knot at 5 points (GDS-15) to flexibly model the association of GDS-15 scores with poor health states.

Results: Totally, 1,002 participants were included in this study for analysis. Participants' median age was 102 years, and 82.04% were female. The median EQ-5D index was 0.68 (range: −0.149–1), and the mean VAS and GDS-15 scores were 61.60 (range: 0–100), and 5.23 (range: 0–15), respectively. Centenarians with MnDD and MDD accounted for 38.12 and 9.98%, respectively. While those with poor health states accounted for 45.11%. For every 1-point increase in GDS-15, the risk of poor health state increased by 20% (P < 0.001) after an adjustment for age, gender, ethnicity, marital status, education, residence type, smoking, drinking, weekly exercise, body mass index category, serum albumin, 25-hydroxyvitamin D, C-reactive protein, and comorbidities. MnDD and MDD were independent risk factors for poor health state (MnDD, OR = 2.76, P < 0.001; MDD, OR = 3.14, P < 0.001). The association was more prominent in centenarians without comorbidity.

Conclusions: This study demonstrated a negative association between depression and HRQoL in Chinese centenarians, especially in centenarians without comorbidity. Large-scale prospective studies are needed to corroborate our findings and provide more information about the causal inference and internal mechanisms of this association.

Antioxidant Lifestyle, Co-Morbidities and Quality of Life Empowerment Concerning Liver Fibrosis

The assessment of liver fibrosis has gained importance since the progression of non-alcoholic fatty liver disease (NAFLD). Indeed, the description of the association between undetected liver fibrosis and lifestyle in terms of antioxidant habits, comorbidity and quality of life (QoL) domains may help in the characterization of subjects with NAFLD. A cross-sectional evaluation of (n = 116) consecutive patients from an Internal Medicine ambulatory evaluation was performed. Demographic data, lifestyle, co-morbidity, QoL (according to the SF-36 index) and analytical values to calculate the oxidative related Fibrosis-4 (FIB-4) index were recorded. The association between FIB-4 and co-morbidity, antioxidant habits in QoL was assessed in univariate analysis (p < 0.05) and confirmed in multivariable analysis for 4 of the 8 SF-36 categories: Physical QoL, Physical role, Social QoL and General QoL, as well as in the Physical summary of SF-36 (p < 0.05). Finally, interactions were assessed between co-morbidity, FIB-4 and antioxidant habits showed in the prediction of mean SF-36 (p < 0.01). Liver fibrosis assessed by the oxidative surrogate index FIB-4 is associated with the interaction between antioxidant lifestyle, co-morbidity and physical, social and general aspects of QoL in apparent liver disease-free individuals, generating a proof of concept for health empowerment and personalized medicine.

Quality of life and mortality in the general population: a systematic review and meta-analysis

BACKGROUND

Quality of life (QoL) is multi-dimensional concept of an individual' general well-being status in relation to their value, environment, cultural and social context in which they live. This study aimed to quantitatively synthesise available evidence on the association between QoL and mortality in the general population.

METHODS

An electronic search was conducted using three bibliographic databases, MEDLINE, EMBASE and PsycINFO. Inclusion criteria were studies that assessed QoL using standardized tools and examined mortality risk in a non-patient population. Qualitative data synthesis and meta-analyses using a random-effects model were performed.

RESULTS

Of 4184 articles identified, 47 were eligible for inclusion, involving approximately 1,200,000 participants. Studies were highly heterogeneous in terms of QoL measures, population characteristics and data analysis. In total, 43 studies (91.5%) reported that better QoL was associated with lower mortality risk. The results of four meta-analyses indicated that higher health-related QoL (HRQoL) is associated with lower mortality risk, which was consistent for overall HRQoL (HR 0.633, 95% CI: 0.514 to 0.780), physical function (HR 0.987, 95% CI: 0.982 to 0.992), physical component score (OR 0.950, 95% CI: 0.935 to 0.965), and mental component score (OR 0.980, 95% CI: 0.969 to 0.992).

CONCLUSION

These findings provide evidence that better QoL/HRQoL was associated with lower mortality risk. The utility of these measures in predicting mortality risk indicates that they should be considered further as potential screening tools in general clinical practice, beyond the traditional objective measures such as body mass index and the results of laboratory tests.

Role of clinical, functional and social factors in the association between multimorbidity and quality of life: Findings from the Survey of Health, Ageing and Retirement in Europe (SHARE)

OBJECTIVE

An increasing number of diseases is linked to deterioration of quality of life (QoL). Part of this association can be explained by socio-economic factors, which are most commonly accounted for. Our aim was to explore the potential contribution of other factors related to clinical burden, social interaction and functioning.

METHODS

A cross-sectional analysis was conducted on wave 6 of the population-based Survey of Health, Ageing and Retirement in Europe (SHARE), among participants aged 50+ (n = 67 179). The Control, Autonomy, Self-Realization and Pleasure (CASP-12v1) questionnaire measured QoL. The association between number of diseases and QoL was tested in a mixed-effects linear regression model. The base model controlled for socio-economic characteristics. Factors of interest (symptoms, polypharmacy, unmet care needs, utilisation of care, social network, personal and financial help, loneliness and activities of daily living (ADL) with instrumental activities (IADL)) were added to the base model one at a time and tested for relevance (i.e. change in the β-coefficient of the number of conditions of 15% or more).

RESULTS

Symptoms, polypharmacy, loneliness and ADL/IADL appeared relevant and were retained in the final model. The association between number of conditions and QoL in the base model was -2.44 [95% CI: -2.72; -2.16], while this association was -0.76 [95%CI: -0.97; -0.54] after all relevant factors were included.

CONCLUSION

Factors beyond the socio-economic circumstances play an important role in explaining the association between number of conditions and QoL. These factors should be considered to better estimate the impact of chronic diseases on QoL, and for improving patient care.

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.

Patients' preferences for health insurance coverage of new technologies for treating chronic diseases in China: a discrete choice experiment

OBJECTIVES

Our study aimed to inform insurance decision-making in China by investigating patients' preferences for insurance coverage of new technologies for treating chronic diseases.

DESIGN

We identified six attributes of new medical technologies for treating chronic diseases and used Bayesian-efficient design to generate choice sets for a discrete choice experiment (DCE). After conducting the DCE, we analysed the data by mixed logit regression to examine patient-reported preferences for each attribute.

SETTING

The DCE was conducted with patients in six tertiary hospitals from four cities in Jiangsu province.

PARTICIPANTS

Patients aged 18 years or older with a history of diabetes or hypertension and taking medications regularly for more than 1 year were recruited (n=408).

RESULTS

The technology attributes regarding expected gains in health outcomes from the treatment, high likelihood of effective treatment and low incidence of serious adverse events were significant, positive predictors of choice by the study patients (p<0.01). The out-of-pocket cost was a significant, negative attribute for the entire study sample (β = -0.258, p<0.01) and for the patients with Urban-Rural Residents Basic Medical Insurance (URRBMI) (β = -0.511, p<0.01), but not for all the patients with Urban Employees Basic Medical Insurance (UEBMI) (β = -0.071, p>0.05). The severity of target disease was valued by patients with lower EQ-5D-5L index value as well as URRBMI enrollees.

CONCLUSIONS

Patients highly valued the health benefits and risks of new technologies, which were closely linked to their feelings of disease and perceptions of health-related quality of life. However, there existed heterogeneity in preferences between URRBMI and UEBMI patients. Further efforts should be made to reduce the gap between insurance schemes and make safe and cost-effective new technologies as a priority for health insurance reimbursement.

Health-related quality of life in patients with non-communicable disease: study protocol of a cross-sectional survey

INTRODUCTION

Non-communicable diseases (NCDs) are associated with lower health-related quality of life (HRQoL). However, knowledge about those diseases and predictors with a greater impact on patients' HRQoL as well as knowledge on the complex relationship between HRQoL and comorbidities is lacking. The aim of this study is to assess the impact of NCDs on patients' HRQoL, with a focus on multimorbidity and socioeconomic status.

METHODS AND ANALYSIS

A primary care-based cross-sectional study is conducted in Flanders (Belgium). Study participants (≥18 years) are medically diagnosed with at least one of the following diseases: cardiometabolic disorders, mental disorders and musculoskeletal disorders. A minimum of 50 general practitioners will participate to recruit participants (convenient sample) and a total of 531 patients will be enrolled (voluntary response sample). Each participant will complete a paper-based questionnaire to gather research outcomes. Statistical analyses will be performed using multiple linear regression models with HRQoL as main outcome parameter, adjusted for possible confounders. This study will generate new evidence on the key predictors of HRQoL in patients with NCDs, and particularly provide new insights in multimorbidity to improve the quality of care in primary care, to support patients' self-management and to allocate resources more effectively.

ETHICS AND DISSEMINATION

The study has been approved by the Ethical Committee of Ghent University Hospital, Ghent, Belgium (reference number: B670201939629) prior to the beginning of the recruitment. Study results will be disseminated through peer-reviewed publications and conference presentations.

Identifying Adherence Patterns Across Multiple Medications and Their Association With Health Outcomes in Older Community-Dwelling Adults With Multimorbidity

OBJECTIVES

To classify older people with multimorbidity according to their adherence patterns and to examine the association between medication adherence and health outcomes.

METHODS

This is a secondary analysis of a cohort study. Community-dwelling adults aged ≥70 years were recruited from 15 general practices in Ireland in 2010 (wave 1) and followed up 2 years later (wave 2). Participants had ≥2 RxRisk-V multimorbidity conditions at wave 1 and had ≥2 dispensations of RxRisk-V medications (wave 1-wave 2). Average adherence across RxRisk-V conditions was estimated based on continuous multiple-interval measure of medication availability (CMA7 function in AdhereR). Group-based trajectory models were used to group participants' adherence patterns for RxRisk-V medications. Multilevel regression was used to examine the association between adherence and (1) EuroQol 5-dimension (EQ-5D) utility (linear) and (2) vulnerability, using the Vulnerable Elders Survey (≥3 defined as vulnerable; logistic) at wave 2, controlling for potential confounders.

RESULTS

Average adherence (CMA7) was 77% across 501 participants. Group-based trajectory models identified 5 adherence groups: (1) initial low adherers, gradual increase; (2) high adherers, sharp decline; (3) steady adherers, gradual decline; (4) consistent high adherers; and (5) consistent nonadherers. Higher average adherence was associated with a significant increase in EQ-5D utility (adjusted β = 0.11, robust standard error 0.04). Group 5 was associated with significantly increased vulnerability compared to group 4 (adjusted odds ratio = 1.88; 95% confidence interval 1.01-3.50).

CONCLUSION

Increased average adherence was associated with higher EQ-5D utility. Adherence grouping did not significantly impact utility. Suboptimal adherence to multiple medications in older adults with multimorbidity was associated with vulnerability.

Anticholinergic Burden Measures Predict Older People's Physical Function and Quality of Life: A Systematic Review

OBJECTIVES

This systematic review (PROSPERO CRD42019115918) compared the evidence behind anticholinergic burden (ACB) measures and their ability to predict changes in older people's physical function and quality of life.

DESIGN

Eligible cohort or case-control studies were identified systematically using comprehensive search terms and a validated search filter for prognostic studies. Medline (OVID), EMBASE (OVID), CINAHL (EMBSCO), and PsycINFO (OVID) databases were searched. Risk of bias, using Quality in Prognosis Studies tool, and quality of evidence, using the Grading of Recommendations, Assessment, Development and Evaluation, were assessed.

SETTING AND PARTICIPANTS

People aged 65 years and older from any clinical setting.

MEASURES

Any ACB measures were accepted (including the anticholinergic domain of the Drug Burden Index). Any global/multidimensional measure for physical function and/or quality of life was accepted for outcome.

RESULTS

Thirteen studies reporting associations between ACB and physical function (n = 10) or quality of life (n = 4) were included. Exposure measures included Anticholinergic Cognitive Burden Scale, Anticholinergic Drug Scale, Anticholinergic Risk Scale, Clinician Rated Anticholinergic Score, and the anticholinergic domain of the Drug Burden Index. All studies were rated moderate risk of bias in ≥2 Quality in Prognosis Studies categories with 5 rated high risk in ≥1 categories. Seven of 10 studies (5251 of 7569 participants) reported significant decline in physical function with increased burden. All 4 studies (2635 participants) reporting quality of life demonstrated similar association with increased burden. High risk of biases and inadequate data reporting restricted analysis. There was no evidence to support one measure being superior to another.

CONCLUSIONS AND IMPLICATIONS

The evidence supports association between increased ACB and future impairments in physical function and quality of life. No conclusion can be made regarding which ACB measure has the best prognostic value. Well-designed longitudinal studies are required to address this. Clinicians should be aware of patient's anticholinergic burden and consider alternative medications where appropriate.

Association of Sustained Blood Pressure Control with Multimorbidity Progression Among Older Adults

BACKGROUND/OBJECTIVES

Due to the high costs and excess mortality associated with multimorbidity, there is a need to develop approaches for delaying its progression. High blood pressure (BP) is a common chronic condition and a risk factor for many additional chronic conditions, making it an ideal target for intervention. The purpose of this analysis was to determine the association between the level of sustained BP control and the progression of multimorbidity.

DESIGN

Retrospective cohort study.

SETTING

Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) linked to Medicare claims.

PARTICIPANTS

A total of 6,591 ALLHAT participants with Medicare who had systolic BP (SBP) measurements at eight or more study visits.

MEASUREMENTS

SBP control was categorized as lower than 140 mm Hg at less than 50%, 50% to less than 75%, 75% to less than 100%, and 100% of visits. Multimorbidity progression was defined by the number of incident chronic conditions, including arthritis, asthma, atrial fibrillation, cancer, chronic kidney disease, chronic obstructive pulmonary disease, coronary heart disease, dementia, depression, diabetes mellitus, heart failure, hyperlipidemia, osteoporosis, and stroke. Recurrent event survival analysis was used to calculate rate ratios (RRs) for the association of sustained SBP control with progression of multimorbidity.

RESULTS

Rates of incident conditions per 10 person-years (95% CIs) were 5.2 (5.1-5.4), 4.7 (4.5-4.8), 4.4 (4.2-4.5), and 4.0 (3.8-4.2) for participants with SBP control at less than 50%, 50% to less than 75%, 75% to less than 100%, and 100% of visits, respectively, over a median follow-up of 9.0 years. Compared with participants with SBP control at less than 50% of visits, adjusted RRs (95% CIs) for multimorbidity progression were 0.90 (0.86-0.95), 0.85 (0.81-0.89), and 0.77 (0.72-0.82) for those with SBP control at 50% to less than 75%, 75% to less than 100%, and 100% of visits, respectively.

CONCLUSIONS

Sustaining BP control may be an effective approach to slow multimorbidity progression and may reduce the population burden of multimorbidity.

Nutritional Determinants of Quality of Life in a Mediterranean Cohort: The SUN Study

Health related quality of life (HRQoL) is a subjective appreciation of how personal characteristics and health influence well-being. This cross-sectional analysis aimed to quantitatively measure the influence of dietary, lifestyle, and demographic factors on HRQoL. A sub-sample of the Seguimiento Universidad de Navarra (SUN) Project, a Mediterranean cohort, was analyzed (n = 15,674). Through self-administered questionnaires the relationship between HRQoL and dietary patterns (Mediterranean-diet (MedDiet) and provegetarian food pattern (FP) assessment), lifestyles (sleeping hours, physical activity) and demographic characteristics were measured. Multivariate linear regression and flexible regression models were used to estimate the pondered effect of personal factors on Short Form-36 (SF-36) scores. Coefficients for MedDiet and provegetarian scores (β-coefficient for global SF-36 score: 0.32 (0.22, 0.42); 0.09 (0.06, 0.12) respectively for every unit increase), physical activity (β: 0.03 (0.02, 0.03) for every metabolic equivalent of task indexes (MET)-h/week) had a positive association to HRQoL. The female sex (β: −3.28 (−3.68, −2.89)), and pre-existing diseases (diabetes, β: −2.27 (−3.48, −1.06), hypertension β: −1.79 (−2.36, −1.22), hypercholesterolemia β: −1.04 (−1.48, −0.59)) account for lower SF-36 scores. Adherence to MedDiet or provegetarian FP, physical activity and sleep are associated with higher HRQoL, whereas the female sex, “other” (versus married status) and the presence of chronic diseases were associated with lower SF-36 scores in this sample.

Physical activity promotion for multimorbid patients in primary care settings: a protocol for a systematic review evaluating health benefits and harms

BACKGROUND

To date multimorbidity has not received much attention in health policies, even though multiple chronic diseases put high demands on the health care system in industrial nations. Enormous costs of care and a physically, mentally, and socially reduced quality of life are common consequences of multimorbidity. Physical activity (PA) has a positive preventive and therapeutic effect on common non-communicable diseases. The objective of this study will be to evaluate the health benefits and harms of PA interventions for sedentary adults with multimorbidity in primary care settings.

METHODS

This is the study protocol for a systematic review. We will search PubMed, MEDLINE (Ovid), Web of Science, CINHAL, and the Cochrane Library (from inception onwards). In addition, clinical trial registers and reference lists of included studies will be searched. We will include randomized controlled trials, quasi-experimental, and non-randomized trials examining the health benefits and harms of PA interventions with or without additional lifestyle interventions for sedentary adult patients with multimorbidity (e.g., two or more chronic non-communicable diseases) in primary care. Eligible control groups will be standard care, placebo, or medications. Two reviewers will independently screen all citations, abstracts data, and full-text articles. The primary outcomes will be health-related quality of life and mortality. Secondary outcomes will include cardiovascular fitness, muscular strength and disease-specific outcomes (e.g., depression score), biomarkers as well as control of metabolic risk factors (e.g., blood pressure, HBA1c, body weight) and any adverse event. The methodological quality of the studies will be appraised using appropriate tools. If feasible, we will conduct random effects meta-analysis. Additional analyses will be conducted to explore the potential sources of heterogeneity (e.g., study design, geographical location, or type of intervention). Strength of the body of evidence will be assessed according to the Grading of Recommendations Assessment (GRADE).

DISCUSSION

This review will evaluate the evidence on health benefits and harms of PA interventions for sedentary adults with multimorbidity in primary care settings. We anticipate our findings to be of interest to patients, their families, caregivers, and healthcare professionals in selecting and conducting optimal health promotion programs. Possible implications for further research will be discussed.

SYSTEMATIC REVIEW REGISTRATION

Open Science Framework (registration identifier: osf.io/ka8yu).

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.

The Need for Co-Creation of Care with Multi-Morbidity Patients-A Longitudinal Perspective

Background: Primary care delivery for multimorbid patients is complex, due to single disease–oriented guidelines, complex care needs, time constraints and the involvement of multiple healthcare professionals. Co-creation of care, based on the quality of communication and relationships between healthcare professionals and patients, may therefore be valuable. This longitudinal study investigates the relationships of co-creation of care to physical and social well-being and satisfaction with care among multimorbid patients in primary care. Methods: In 2017 and 2018, longitudinal surveys were conducted among multimorbid patients from seven primary care practices in Noord-Brabant, the Netherlands (n = 138, age = 73.50 ± 9.99). Paired sample t-tests and multivariate regression analyses were performed. (3) Results: Co-creation of care improved significantly over time (t = 2.25, p = 0.026), as did social well-being (t = 2.31, p = 0.022) and physical well-being (t = 2.72, p = 0.007) but not satisfaction with care (t = 0.18, p = 0.858). Improvements in co-creation of care from T0 to T1 were associated with social well-being (B = 0.157, p = 0.002), physical well-being (B = 0.216, p = 0.000) and satisfaction with care (B = 0.240, p = 0.000). (4) Conclusions: Thus, investment in co-creation of care by primary care practices may lead to better outcomes for multimorbid patients.

Views of patients with multi-morbidity on what is important for patient-centered care in the primary care setting

BACKGROUND

Patient-centered care (PCC) has been proposed as the way forward in improving primary care for patients with multi-morbidity. However, it is not clear what PCC exactly looks like in practice for patients with multi-morbidity. A better understanding of multi-morbid patients' views on what PCC should look like and which elements are most important may help to improve care delivery for this vulnerable population. The present study thus aimed to identify views of patients with multi-morbidity on the relative importance of PCC aspects in a Dutch primary care setting.

METHODS

Interviews were conducted with 16 patients with multi-morbidity using Q-methodology, which combines quantitative and qualitative analyses. The participants ranked 28 statements about the eight dimensions of PCC (patients' preferences, information and education, access to care, emotional support, family and friends, continuity and transition, physical comfort, and coordination of care) by relative importance. By-person factor analysis using centroid factor extraction and varimax rotation were used to reveal factors that represent viewpoints. Qualitative interview data were used to interpret the viewpoints.

RESULTS

The analyses revealed three factors representing three distinct viewpoints of patients with multi-morbidity on what is important for patient-centered care in the primary care setting. Patients with viewpoint 1 are prepared proactive patients who seem to be well-off and want to be in charge of their own care. To do so, they seek medical information and prefer to be supported by a strongly coordinated multidisciplinary team of healthcare professionals. Patients with viewpoint 2 are everyday patients who visit GPs and require well-coordinated, respectful, and supportive care. Patients with viewpoint 3 are vulnerable patients who are less resourceful in terms of communication skills and finances, and thus require accessible care and professionals taking the lead while treating them with dignity and respect.

CONCLUSION

The findings of this study suggest that not all patients with multi-morbidity require the same type of care delivery, and that not all aspects of PCC delivery are equally important to all patients.

Depression and self-care in older adults with multiple chronic conditions: A multivariate analysis

AIMS

To investigate the relationship between depression and self-care behaviours in older individuals with multimorbidity.

DESIGN

Cross-sectional study. Data were collected between April 2017 - June 2019.

METHODS

Patients were enrolled from community and outpatient settings and included if they were ≥65 years, affected by heart failure, diabetes mellitus or chronic obstructive pulmonary disease and at least another chronic condition. They were excluded if they had dementia and/or cancer. Patient Health Questionnaire-9 was used to measure depression and Self-Care of Chronic Illness Inventory was used to measure self-care maintenance, monitoring, and management. The relationship between depression and self-care was evaluated by performing two sets of univariate analyses, followed by multivariate and step-down analyses. The second set was performed to control for the number of chronic conditions, age, and cognitive function.

RESULTS

The sample (N = 366) was mostly female (54.2%), with a mean age of 76.4 years. Most participants (65.6%) had mild to very severe depressive symptoms. Preliminary analysis indicated a significant negative association between depression and self-care maintenance and monitoring and a significant negative association between depression and multivariate self-care. Step-down analysis showed that self-care maintenance was the only dimension negatively associated with depression, even after controlling for the number of chronic conditions, age, and cognitive function.

CONCLUSION

In multimorbid populations, depression is more likely to be associated with self-care maintenance than the other self-care dimensions. Therefore, self-care maintenance behaviours (e.g., physical activity and medication adherence) should be prioritized in assessment and focused on when developing interventions targeting depressed older adults with multimorbidity.

IMPACT

The results of this study may help guide clinical practice. In patients with depressive symptoms, self-care maintenance behaviours should be assessed first, as a potential first indicator of poor self-care.

Associations between complex multimorbidity, activities of daily living and mortality among older Norwegians. A prospective cohort study: the HUNT Study, Norway

Background

With increasing age, having multiple chronic conditions is the norm. It is of importance to study how co-existence of diseases affects functioning and mortality among older persons. Complex multimorbidity may be defined as three or more conditions affecting at least three different organ systems. The aim of this study was to investigate how complex multimorbidity affects activities of daily living and mortality amongst older Norwegians.

Methods

Participants were 60–69-year-olds at baseline in the Nord-Trøndelag Health Study 1995-1997 (HUNT2) n = 9058. Multinomial logistic regression models were used to investigate the association between complex multimorbidity in HUNT2, basic and instrumental activities of daily living in HUNT3 (2006–2008) and mortality during follow-up (n = 5819/5836). Risk ratios (RR) and risk differences (RD) in percentage points (pp) with 95% confidence intervals (CI) were reported.

Results

47.8% of 60–69-year-olds met the criteria of complex multimorbidity at baseline (HUNT2). Having complex multimorbidity was strongly associated with the need for assistance in IADL in HUNT3 11 years later (RR = 1.80 (1.58–2.04) and RD = 8.7 (6.8–10.5) pp) and moderately associated with mortality during the follow-up time (RR = 1.22 (1.12–1.33) and RD = 5.1 (2.9–7.3) pp). Complex multimorbidity was to a lesser extent associated with basic activities of daily living 11 years later (RR = 1.24 (0.85–1.83) and RD = 0.4 (− 0.3–1.1) pp).

Conclusions

This is the first study to show an association between complex multimorbidity and activities of daily living. Complex multimorbidity should receive more attention in order to prevent future disability amongst older persons.

Bayesian Hierarchical Models for Meta-Analysis of Quality-of-Life Outcomes: An Application in Multimorbidity

BACKGROUND

Health-related quality of life (HRQoL) is a key outcome in cost-utility analyses, which are commonly used to inform healthcare decisions. Different instruments exist to evaluate HRQoL, however while some jurisdictions have a preferred system, no gold standard exists. Standard meta-analysis struggles with the variety of outcome measures, which may result in the exclusion of potentially relevant evidence.

OBJECTIVE

Using a case study in multimorbidity, the objective of this analysis is to illustrate how a Bayesian hierarchical model can be used to combine data across different instruments. The outcome of interest is the slope relating HRQoL to the number of coexisting conditions.

METHODS

We propose a three-level Bayesian hierarchical model to systematically include a large number of studies evaluating HRQoL using multiple instruments. Random effects assumptions yield instrument-level estimates benefitting from borrowing strength across the evidence base. This is particularly useful where little evidence is available for the outcome of choice for further evaluation.

RESULTS

Our analysis estimated a reduction in quality of life of 3.8-4.1% per additional condition depending on HRQoL instrument. Uncertainty was reduced by approximately 80% for the instrument with the least evidence.

CONCLUSION

Bayesian hierarchical models may provide a useful modelling approach to systematically synthesize data from HRQoL studies.

Associations Between Multimorbidity and Cerebrospinal Fluid Amyloid: A Cross-Sectional Analysis of the European Prevention of Alzheimer's Dementia (EPAD) V500.0 Cohort

BACKGROUND

Multimorbidity (the co-occurrence of multiple chronic conditions) is increasingly common, especially among people with dementia. Few neuroimaging studies have explored amyloid biomarkers in people with multimorbidity.

OBJECTIVE

We aimed to conduct the first study of the association between multimorbidity and cerebrospinal fluid amyloid-β42 (CSF Aβ).

METHOD

The European Prevention of Alzheimer's Dementia (EPAD) Longitudinal Cohort Study V500.0 dataset includes volunteers aged ≥50 years from 12 sites. Participants undergo detailed phenotyping, including CSF measures and a self-reported medical history. Using logistic and linear regression analyses, we explored the association between multimorbidity and continuous chronic condition count with CSF Aβ positivity (Aβ42 <1000pg/ml) and continuous CSF Aβ concentration. All models were adjusted for age, sex, APOE status, education, and family history of dementia.

RESULTS

Among 447 eligible participants without dementia, the mean (SD) age was 66.6 (6.6) years, 234 (52.3%) were women, and 157 (35.1%) were amyloid positive. With chronic conditions regarded as pseudo-continuous, each additional condition carried a decreased likelihood of amyloid positivity (OR = 0.82, 95% CI: 0.68-0.97; p = 0.026). With CSF Aβ as a continuous variable, each additional condition was associated with an increase of 54.2 pg/ml (95% CI: 9.9-98.5, p = 0.017). Having ≥2 conditions was inversely associated with amyloid positivity (OR 0.59, 95% CI: 0.37-0.95, p = 0.030) compared to one or none.

CONCLUSION

Our findings suggest that the established association between multimorbidity and dementia may be due to a pathway other than amyloid. However, this cross-sectional study does not allow us to make causal inferences. Longitudinal work is required to confirm the inverse association found.

Health related quality of life in multimorbidity: a primary-care based study from Odisha, India

BACKGROUND

Multimorbidity, the coexistence of two or more chronic conditions is increasingly prevalent in primary care populations. Despite reports on its adverse impact on health outcomes, functioning and well-being, it's association with quality of life is not well known in low and middle income countries. We assessed the health-related quality of life (HRQoL) of primary care patients with multimorbidity and identified the influencing factors.

METHODS

This cross-sectional study was done across 20 public and 20 private primary care facilities in Odisha, India. Data were collected from 1649 adult out-patients using a structured multimorbidity assessment questionnaire for primary care (MAQ-PC). HRQoL was assessed by the 12-item short-form health survey (SF-12). Both physical (PCS) and mental components scores (MCS) were calculated. Multiple regression analysis was performed to determine the association of HRQoL with socio-demographics, number, severity and typology of chronic conditions.

RESULTS

Around 28.3% [95% CI: 25.9-30.7] of patients had multimorbidity. Mean physical component scope (PCS) and mental component score (MCS) of QoL in the study population was 43.56 [95% CI: 43.26-43.86] and 43.69 [95% CI: 43.22-44.16], respectively. Patients with multimorbidity reported poorer mean PCS [43.23, 95% CI: 42.62-43.84] and MCS [41.58, 95% CI: 40.74-42.43] compared to those without. After adjusting for other variables, morbidity severity burden score was found to be negatively associated with MCS [adjusted coefficient: -0.24, 95% CI - 0.41 to - 0.08], whereas no significant association was seen with PCS. Hypertension and diabetes with arthritis and acid peptic diseases were found to be negatively related with MCS. Within multimorbidity, lower education was inversely associated with mental QoL and positively associated with physical QoL score after adjusting for other variables.

CONCLUSION

Our findings demonstrate the diverse negative effects of multimorbidity on HRQoL and reveal that apart from count of chronic conditions, severity and pattern also influence HRQoL negatively. Health care providers should consider severity as an outcome measure to improve QoL especially in individuals with physical multimorbidity. Given the differences observed between age groups, it is important to identify specific care needs for each group. Musculoskeletal clusters need prioritised attention while designing clinical guidelines for multimorbidity.