[Development of clinical practice guidelines for patients with comorbidity and multiple diseases]

Adjusted morbidity groups and survival: a retrospective cohort study of primary care patients with chronic conditions

BACKGROUND

Chronic conditions are one of the main determinants of frailty, functional disability, loss of quality of life and the number one cause of death worldwide. This study aimed to describe the survival of patients with chronic conditions who were followed up in primary care according to the level of risk by adjusted morbidity groups and to analyse the effects of sex, age, clinician and care factors on survival.

METHODS

This was a longitudinal observational study of a retrospective cohort of patients with chronic conditions identified by the adjusted morbidity group stratifier of the electronic medical records in a primary health centre of the Region of Madrid, which has an assigned population of 18,107 inhabitants. The follow-up period was from June 2015 to June 2018. A description of survival according to the Kaplan-Meier method and Cox proportional hazards multivariate regression model was used to analyse the effects of sex, age, clinician and care factors.

RESULTS

A total of 9,866 patients with chronic conditions were identified; 77.4% (7,638) had a low risk, 18.1% (1,784) had a medium risk, and 4.5% (444) had a high risk according to the adjusted morbidity groups. A total of 477 patients with chronic conditions died (4.8%). The median survival was 36 months. The factors associated with lower survival were age over 65 years (hazard ratio [HR] = 1.3; 95% confidence interval [CI] = 1.1-1.6), receiving palliative care (HR = 3.4; 95% CI = 2.6-4.5), high versus low risk level (HR = 2.4; 95% CI = 1.60-3.7), five chronic conditions or more (HR = 1.5; 95% CI = 1.2-2), complexity index (HR = 1.01; 95% CI = 1.02-1.04) and polymedication (HR = 2.6; 95% CI = 2.0-3.3).

CONCLUSIONS

There was a gradual and significant decrease in the survival of patients with chronic conditions according to their level of risk as defined by adjusted morbidity groups. Other factors, such as older age, receiving palliative care, high number of chronic conditions, complexity, and polymedication, had a negative effect on survival. The adjusted morbidity groups are useful in explaining survival outcomes and may be valuable for clinical practice, resource planning and public health research.

Comorbidity and osteoporotic fracture: approach through predictive modeling techniques using the OSTEOMED registry

Purpose

To examine the response to anti-osteoporotic treatment, considered as incident fragility fractures after a minimum follow-up of 1 year, according to sex, age, and number of comorbidities of the patients.

Methods

For this retrospective observational study, data from baseline and follow-up visits on the number of comorbidities, prescribed anti-osteoporotic treatment and vertebral, humerus or hip fractures in 993 patients from the OSTEOMED registry were analyzed using logistic regression and an artificial network model.

Results

Logistic regression showed that the probability of reducing fractures for each anti-osteoporotic treatment considered was independent of sex, age, and the number of comorbidities, increasing significantly only in males taking vitamin D (OR = 7.918), patients without comorbidities taking vitamin D (OR = 4.197) and patients with ≥ 3 comorbidities taking calcium (OR = 9.412). Logistic regression correctly classified 96% of patients (Hosmer–Lemeshow = 0.492) compared with the artificial neural network model, which correctly classified 95% of patients (AUC = 0.6).

Conclusion

In general, sex, age and the number of comorbidities did not influence the likelihood that a given anti-osteoporotic treatment improved the risk of incident fragility fractures after 1 year, but this appeared to increase when patients had been treated with risedronate, strontium or teriparatide. The two models used classified patients similarly, but predicted differently in terms of the probability of improvement, with logistic regression being the better fit.

Chronic diseases in the geriatric population: morbidity and use of primary care services according to risk level

BACKGROUND

Geriatric patients have significant morbidity and greater needs for care and assistance. The objective of this study was to describe the characteristics, morbidity, and use of services in primary care (PC) of patients with chronic diseases older than 65 years according to their risk level assigned by the adjusted morbidity groups (AMG) and to analyse the factors associated with the use of PC services.

METHODS

This was a cross-sectional descriptive observational study. Patients older than 65 years from a healthcare service area, classified as chronically ill by the AMG classification system of the PC electronic medical record of the Community of Madrid, were included. Sociodemographic, clinical-care, and PC service utilization variables were collected. Univariate, bivariate and multivariate analyses were done.

RESULTS

A total of 3292 chronic patients older than 65 years were identified, of whom 1628 (49.5%) were low risk, 1293 (39.3%) were medium risk and 371 (11.3%) were high risk. Their mean age was 78.1 (SD = 8.1) years and 2167 (65.8%) were women. Their mean number of chronic diseases was 3.8 (SD = 2), 89.4% had multimorbidity and 1550 (47.1%) were polymedicated. The mean number of contacts/year with PC was 19.5 (SD = 18.2) [men: 19.4 (SD = 19.8); women: 19.5 (SD = 17.4)]. The mean number of contacts/year in people over 85 years was 25.2 (SD = 19.6); in people 76-85 years old, it was 22.1 (SD = 20.3); and in people 66-75 years old, it was 14.5 (SD = 13.9). The factors associated with greater use of services were age (B coefficient [BC] = 0.3; 95%CI = 0.2-0.4), high risk level (BC = 1.9; 95%CI =0.4-3.2), weight of complexity (BC = 0.7; 95%CI = 0.5-0.8), and ≥ 4 chronic diseases (BC = 0.7; 95%CI = 0.3-1.1).

CONCLUSIONS

In the geriatric population, we found a high number of patients with chronic diseases and there were three levels of risk by AMG with differences in characteristics, morbidity, and use of PC services. The greatest use of services was by patients with older age, high risk level, greater weight of complexity and ≥ 4 chronic diseases. Further research is needed to develop an intervention model more adapted to the reality of the geriatric population based on risk levels by AMG.

Caracterización sociodemográfica y clínica de pacientes con enfermedad renal crónica en condición de pluripatología y sus cuidadores

Introducción: Los pacientes con Enfermedad Renal Crónica en condición de pluripatología presentan deterioro funcional progresivo, vulnerabilidad clínica, polifarmacia, disminución de calidad de vida, impacto psicosocial y alto costo para la persona y  familia. Enfermería debe conocer las características clínicas y sociodemográficas para identificar las necesidades. Objetivo: Establecer a través de una valoración multidimensional las condiciones sociodemográficas y clínicas de pacientes pluripatológicos con enfermedad renal crónica y sus cuidadores familiares. Material y Método: Estudio descriptivo de corte transversal, participaron 97 personas con enfermead renal crónica en situación de pluripatología y sus cuidadores familiares, afiliados a dos aseguradoras de Bogotá, Colombia. Se realizó valoración multidimensional al paciente y cuidador con instrumentos validados. Análisis descriptivo, se utilizó STATA versión 13.  Resultados: El 52,6% fueron mujeres mayores de 80 años, 48% estaban casados, todos cursaron primaria completa. Adicional a enfermedad renal, el 43,3%.  presenta tres enfermedades asociadas. El 36,08% reportó independencia total en Actividades Básicas de la Vida Diaria. El 38% presenta riesgo social medio y problemático, y mayor alteración de calidad de vida. Los principales cuidadores son hijos, seguidos de cónyuges. Conclusión: La mayoría de pacientes con ERC en condición de pluripatología presentan tres enfermedades crónicas asociadas, EPOC, cardiopatías y enfermedades mentales. Los resultados reflejan complejidad clínica y psicosocial asociada especialmente a niveles de dependencia funcional y riesgo social. Las dimensiones de calidad de vida más afectadas son función física y rol físico. Los cuidadores familiares principalmente son los hijos, la sobrecarga intensa es baja y la adopción del rol cuidador es adecuada.

Description of multimorbidity clusters of admitted patients in medical departments of a general hospital

OBJECTIVE

We aim to identify patterns of disease clusters among inpatients of a general hospital and to describe the characteristics and evolution of each group.

METHODS

We used two data sets from the CMBD (Conjunto mínimo básico de datos - Minimum Basic Hospital Data Set (MBDS)) of the Lucus Augusti Hospital (Spain), hospitalisations and patients, realising a retrospective cohort study among the 74 220 patients discharged from the Medic Area between 01 January 2000 and 31 December 2015. We created multimorbidity clusters using multiple correspondence analysis.

RESULTS

We identified five clusters for both gender and age. Cluster 1: alcoholic liver disease, alcoholic dependency syndrome, lung and digestive tract malignant neoplasms (age under 50 years). Cluster 2: large intestine, prostate, breast and other malignant neoplasms, lymphoma and myeloma (age over 70, mostly males). Cluster 3: malnutrition, Parkinson disease and other mobility disorders, dementia and other mental health conditions (age over 80 years and mostly women). Cluster 4: atrial fibrillation/flutter, cardiac failure, chronic kidney failure and heart valve disease (age between 70-80 and mostly women). Cluster 5: hypertension/hypertensive heart disease, type 2 diabetes mellitus, ischaemic cardiomyopathy, dyslipidaemia, obesity and sleep apnea, including mostly men (age range 60-80). We assessed significant differences among the clusters when gender, age, number of chronic pathologies, number of rehospitalisations and mortality during the hospitalisation were assessed (p<0001 in all cases).

CONCLUSIONS

We identify for the first time in a hospital environment five clusters of disease combinations among the inpatients. These clusters contain several high-incidence diseases related to both age and gender that express their own evolution and clinical characteristics over time.

[Health care for patients with multimorbidity. The perception of professionals]

Objetivo

Explorar las percepciones de los profesionales sanitarios sobre las características de la atención sanitaria a pacientes con multimorbilidad.

Diseño

Estudio cualitativo de trayectoria fenomenológica realizado entre enero y septiembre de 2015 mediante 3 entrevistas grupales (grupos de discusión) y 15 individuales.

Emplazamiento

Servicio Aragonés de Salud.

Participantes

Profesionales médicos y de enfermería del Servicio Aragonés de Salud pertenecientes a distintos servicios: Medicina Interna, Atención Primaria, Urgencias y Gestión. También se incluyó un farmacéutico.

Métodos

Se realizó un muestreo intencional no probabilístico que permitiese configurar las unidades muestrales buscando criterios de representatividad del discurso, permitiendo conocer e interpretar el fenómeno estudiado en profundidad, en sus diferentes visiones. Se entrevistó a profesionales sanitarios con perfiles diferentes que conociesen en profundidad la atención a pacientes con multimorbilidad. Las entrevistas fueron grabadas, transcritas literalmente e interpretadas, mediante el análisis social del discurso.

Resultados

Se identifica una cultura profesional orientada a la atención de enfermedades individuales, falta de coordinación entre especialidades, pacientes sometidos a numerosas prescripciones, Guías de Práctica Clínica y formación especialmente centradas en enfermedades individuales.

Conclusiones

Tanto la cultura profesional como la organización del sistema sanitario se encuentran orientadas a la atención de enfermedades individuales, lo que redunda en dificultades para ofrecer una atención más integral a los pacientes con multimorbilidad.

Quality of Life and Dependence Degree of Chronic Patients in a Chronicity Care Model

Background: The complex chronic patient is a person with one or several long-term diseases, the clinical management of which are considered difficult and related to cognitive or functional impairment. The chronicity care model deeply affects the quality of life and degree of dependence. Objectives: The objective of this study was to analyse the perceived quality of life and dependence degree in complex chronic patients within a chronicity care model in the Autonomous Communities of Cantabria and the Balearic Islands (Spain). Design: This was a multicentred, transversal, descriptive, and observational study on a cohort of 206 chronic patients included in a chronicity care program. Methods: Patients’ sociodemographic variables, integral valuation, nurse follow-up records, nursing outcomes classification (NOC)/nursing interventions classification (NIC), nurse diagnoses, and hospitalization data were analysed. A descriptive analysis of all data was carried out. The bivariate analysis assessed the relation between covariables and the overall scoring in European Quality of Life Scale (EuroQuol-5D), Barthel, Braden, and Chronic Patient eXperience Assessment Instrument (IEXPAC in the Spanish abbreviation). A multivariate linear regression analysis was conducted. Results: The mean age was 79.4 years (standard deviation (SD) = 9.12; range: 39–94). A percentage of 79.3% of the study population shows functional impairment in one or more activities of daily life. A percentage of 83.3% of patients showed a physical dependence. There is a significant relationship between the gender and kinship degree of the caregiver (χ2 = 18.2; p = 0.001). An overall mean score of 55.38 points in EuroQuol-5D was obtained, along with a 36.87-point satisfaction with the care given in IEXPAC. The overall score correlated positively and significantly with Barthel, Braden, and IEXPAC. The dependence levels improved slightly in the observed patients, which was a very significant outcome in statistical terms (t = 2.08; p = 0.039). A percentage of 66% (R2 = 0.66) of the score variability at the Barthel index could be predicted from Braden scale scoring. Conclusions: Dependence is not only affected by the related pathology, but also by the effect on mobility and daily-life activities, which cause a worse perception of the quality of life. The health-care model based on the case management nurse is having positive effects, especially on dependence and patients with ulcer issues.

Quality of Life and Dependence Degree of Chronic Patients in a Chronicity Care Model

BACKGROUND

The complex chronic patient is a person with one or several long-term diseases, the clinical management of which are considered difficult and related to cognitive or functional impairment. The chronicity care model deeply affects the quality of life and degree of dependence.

OBJECTIVES

The objective of this study was to analyse the perceived quality of life and dependence degree in complex chronic patients within a chronicity care model in the Autonomous Communities of Cantabria and the Balearic Islands (Spain).

DESIGN

This was a multicentred, transversal, descriptive, and observational study on a cohort of 206 chronic patients included in a chronicity care program.

METHODS

Patients' sociodemographic variables, integral valuation, nurse follow-up records, nursing outcomes classification (NOC)/nursing interventions classification (NIC), nurse diagnoses, and hospitalization data were analysed. A descriptive analysis of all data was carried out. The bivariate analysis assessed the relation between covariables and the overall scoring in European Quality of Life Scale (EuroQuol-5D), Barthel, Braden, and Chronic Patient eXperience Assessment Instrument (IEXPAC in the Spanish abbreviation). A multivariate linear regression analysis was conducted.

RESULTS

The mean age was 79.4 years (standard deviation (SD) = 9.12; range: 39-94). A percentage of 79.3% of the study population shows functional impairment in one or more activities of daily life. A percentage of 83.3% of patients showed a physical dependence. There is a significant relationship between the gender and kinship degree of the caregiver (χ2 = 18.2; p = 0.001). An overall mean score of 55.38 points in EuroQuol-5D was obtained, along with a 36.87-point satisfaction with the care given in IEXPAC. The overall score correlated positively and significantly with Barthel, Braden, and IEXPAC. The dependence levels improved slightly in the observed patients, which was a very significant outcome in statistical terms (t = 2.08; p = 0.039). A percentage of 66% (R2 = 0.66) of the score variability at the Barthel index could be predicted from Braden scale scoring.

CONCLUSIONS

Dependence is not only affected by the related pathology, but also by the effect on mobility and daily-life activities, which cause a worse perception of the quality of life. The health-care model based on the case management nurse is having positive effects, especially on dependence and patients with ulcer issues.

Conceptos. Medicina mínimamente disruptiva

En este artículo se presentan algunos conceptos acerca del sobrediagnóstico y sus consecuencias: sobretratamiento y medicalización de la sociedad. Se recuerda el origen del término a partir del cribado y diagnóstico del cáncer y se revisan las estrategias para «sobrediagnosticar», como la modificación de los umbrales diagnósticos de las enfermedades y la conversión de procesos vitales normales, así como los factores de riesgo, en enfermedad. Se exponen algunas estrategias para afrontar el sobrediagnóstico «desde la consulta», como son el manejo de la incertidumbre y la toma compartida de decisiones a través de la correcta interpretación de los estimadores de resultado de diagnóstico y de tratamiento. Finalmente, se presenta la medicina mínimamente disruptiva como la mejor estrategia para afrontar la carga de enfermedad a la que conduce el sobretratamiento en los pacientes con multimorbilidad.

Analysis of home-based rehabilitation in patients with motor impairment in primary care: a prospective observational study

Background

The purpose of health and social policies is to encourage older people more longevity, remain free of disability and experience quality of life while living in their homes.

The aim of this study was to describe the characteristics of 473 patients diagnosed with motor impairment in primary care, the objectives of home-based rehabilitation and its functional impact.

Methods

This prospective observational study was conducted in the Almería Health District. The analysed variables included age, gender, secondary diagnosis, Barthel Index (BI), physiotherapeutic objectives and techniques, and number of sessions.

Results

The sample had a mean age of 83 years, and 59% were women. The assessed conditions with a high prevalence included osteoarticular pathology (55%), Alzheimer’s disease (15.1%), cardiovascular disease (13.7%) and stroke (6.5%). The techniques applied mainly consisted of functional exercises (57.1%), caregiver education (13.8%), and technical assistance (5.7%). There were statistically significant differences (t = −15.79; p < 0.001) between initial (X = 34.8) and final BI (X = 48.1), with an improvement of 13.4 points in patients’ functional capacity (95% confidence interval [CI]: −15.0 to −11.7). An equation was constructed to predict patients’ final BI as a function of the initial BI using a multiple linear regression model. The regression model explained 78% of the variance in patients with motor impairment.

Conclusions

Important improvements were obtained in terms of functional capacity with a mean of ten sessions of physiotherapy. Lower patient age was correlated with higher initial and final functional capacities in primary care. This study aimed to present a useful starting point for decision making among management and health administration regarding this population group by approaching the process from the reality of practice and in relation to the rehabilitation provided.

Trial registration

ClinicalTrials.gov identifier: NCT02715245; Date of registration: 18 January 2016.

[Multimorbidity in general practice and the Ariadne principles. A person-centred approach]

La multimorbilidad, definida como la presencia de dos o más enfermedades crónicas en un mismo individuo, conlleva consecuencias negativas para la persona e importantes retos para los sistemas sanitarios. En atención primaria, donde recae esencialmente la atención de este grupo de pacientes, la consulta es más compleja que la de un paciente con una única enfermedad debido, entre otros, al hecho de tener que manejar mayor cantidad de información clínica, disponer de poca evidencia científica para abordar la multimorbilidad, y tener que coordinar la labor de múltiples profesionales para garantizar la continuidad asistencial. Además, para poder implementar correctamente los planes de tratamiento en estos pacientes es necesario un proceso de toma de decisiones compartida médico-paciente. Entre las distintas herramientas disponibles para apoyar dicho proceso, recientemente se ha desarrollado una dirigida específicamente a pacientes con multimorbilidad en atención primaria y que se describe en el presente artículo: los principios Ariadne.

The association of patient complexities with antibiotic ordering

BACKGROUND

Antibiotic treatment decisions for medically complex patients are complicated, as the risk of undertreatment may be severe, whereas overtreatment may be associated with adverse effects and the emergence of antibiotic resistant pathogens.

OBJECTIVE

To determine the influence of patient complexities on providers' decisions to prescribe antibiotics in 3 common hospital-based clinical vignettes.

DESIGN

A physician survey.

SETTING

Three urban medical centers in Los Angeles County, California.

PARTICIPANTS

Hospital-based physicians.

MEASUREMENTS

Physicians were presented 3 clinical vignettes, with variations by patient age, comorbidity burden, functional status, and follow-up, and asked to choose the best antibiotic regimen. We described the association of additional patient complexity on the proportion of guideline-adherent antibiotic choices.

RESULTS

In the survey, 28% to 49% of physicians recommended antibiotics that were inconsistent with national guidelines. This percentage increased to 48% to 63% for medically complex patients, defined as those with either older age, high medical comorbidity burden, poor functional status, or limited follow-up after hospital discharge (P < 0.01).

CONCLUSIONS

In 3 vignettes depicting common clinical scenarios among hospitalized adults, inappropriate antibiotic use was prevalent and occurred more often for patients with medical complexities. Treatment guidelines should consider addressing medically complex patients in the context of infection management.

[A way of helping "Mr. Minotaur" and "Ms. Ariadne" to exit from the multiple morbidity labyrinth: the "master problems"]

Multiple morbidity seems to be "infinite" and so is not easy to make useful decisions. A new concept is introduced: the "master problems", as a qualitative method to facilitate the exit from this maze of multiple morbidity. Metaphors from the art world have been used to teach this concept. These "master problems" generally remain hidden and can only "unravel" between the interstices of multiple morbidity, when the details of the system that defines the problem are explained. A problem with "energy" or a "master problem" is complex, multiple and dramatic or theatrical--everything in the clinical history history make us look into that particular question. It is what gives us a blow to the stomach, which causes our hearts to beat faster, that moves us on many levels, which has a high "density of emotions", human elements, social symbols, and opens solutions in a patient.