Multimorbidity and its measurement

A Novel Mobile App to Identify Patients With Multimorbidity in the Emergency Setting: Development of an App and Feasibility Trial

BACKGROUND

Multimorbidity is associated with an increased risk of poor surgical outcomes among older adults; however, identifying multimorbidity in the clinical setting can be a challenge.

OBJECTIVE

We created the Multimorbid Patient Identifier App (MMApp) to easily identify patients with multimorbidity identified by the presence of a Qualifying Comorbidity Set and tested its feasibility for use in future clinical research, validation, and eventually to guide clinical decision-making.

METHODS

We adapted the Qualifying Comorbidity Sets' claims-based definition of multimorbidity for clinical use through a modified Delphi approach and developed MMApp. A total of 10 residents input 5 hypothetical emergency general surgery patient scenarios, common among older adults, into the MMApp and examined MMApp test characteristics for a total of 50 trials. For MMApp, comorbidities selected for each scenario were recorded, along with the number of comorbidities correctly chosen, incorrectly chosen, and missed for each scenario. The sensitivity and specificity of identifying a patient as multimorbid using MMApp were calculated using composite data from all scenarios. To assess model feasibility, we compared the mean task completion by scenario to that of the American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator (ACS-NSQIP-SRC) using paired t tests. Usability and satisfaction with MMApp were assessed using an 18-item questionnaire administered immediately after completing all 5 scenarios.

RESULTS

There was no significant difference in the task completion time between the MMApp and the ACS-NSQIP-SRC for scenarios A (86.3 seconds vs 74.3 seconds, P=.85) or C (58.4 seconds vs 68.9 seconds,P=.064), MMapp took less time for scenarios B (76.1 seconds vs 87.4 seconds, P=.03) and E (20.7 seconds vs 73 seconds, P<.001), and more time for scenario D (78.8 seconds vs 58.5 seconds, P=.02). The MMApp identified multimorbidity with 96.7% (29/30) sensitivity and 95% (19/20) specificity. User feedback was positive regarding MMApp's usability, efficiency, and usefulness.

CONCLUSIONS

The MMApp identified multimorbidity with high sensitivity and specificity and did not require significantly more time to complete than a commonly used web-based risk-stratification tool for most scenarios. Mean user times were well under 2 minutes. Feedback was overall positive from residents regarding the usability and usefulness of this app, even in the emergency general surgery setting. It would be feasible to use MMApp to identify patients with multimorbidity in the emergency general surgery setting for validation, research, and eventual clinical use. This type of mobile app could serve as a template for other research teams to create a tool to easily screen participants for potential enrollment.

Defining Multimorbidity in Older Patients Hospitalized with Medical Conditions

BACKGROUND

The term "multimorbidity" identifies high-risk, complex patients and is conventionally defined as ≥2 comorbidities. However, this labels almost all older patients as multimorbid, making this definition less useful for physicians, hospitals, and policymakers.

OBJECTIVE

Develop new medical condition-specific multimorbidity definitions for patients admitted with acute myocardial infarction (AMI), heart failure (HF), and pneumonia patients. We developed three medical condition-specific multimorbidity definitions as the presence of single, double, or triple combinations of comorbidities - called Qualifying Comorbidity Sets (QCSs) - associated with at least doubling the risk of 30-day mortality for AMI and pneumonia, or one-and-a-half times for HF patients, compared to typical patients with these conditions.

DESIGN

Cohort-based matching study PARTICIPANTS: One hundred percent Medicare Fee-for-Service beneficiaries with inpatient admissions between 2016 and 2019 for AMI, HF, and pneumonia.

MAIN MEASURES

Thirty-day all-location mortality KEY RESULTS: We defined multimorbidity as the presence of ≥1 QCS. The new definitions labeled fewer patients as multimorbid with a much higher risk of death compared to the conventional definition (≥2 comorbidities). The proportions of patients labeled as multimorbid using the new definition versus the conventional definition were: for AMI 47% versus 87% (p value<0.0001), HF 53% versus 98% (p value<0.0001), and pneumonia 57% versus 91% (p value<0.0001). Thirty-day mortality was higher among patients with ≥1 QCS compared to ≥2 comorbidities: for AMI 15.0% versus 9.5% (p<0.0001), HF 9.9% versus 7.0% (p <0.0001), and pneumonia 18.4% versus 13.2% (p <0.0001).

CONCLUSION

The presence of ≥2 comorbidities identified almost all patients as multimorbid. In contrast, our new QCS-based definitions selected more specific combinations of comorbidities associated with substantial excess risk in older patients admitted for AMI, HF, and pneumonia. Thus, our new definitions offer a better approach to identifying multimorbid patients, allowing physicians, hospitals, and policymakers to more effectively use such information to consider focused interventions for these vulnerable patients.

The cost-effectiveness of a nursing home-based transitional care unit for increasing the potential for independent living in the community among hospitalized older adults

OBJECTIVE

In Canada, a persistent barrier to achieving healthcare system efficiency has been patient days accumulated by individuals with an alternate level of care (ALC) designation. Transitional care units (TCUs) may address the capacity pressures associated with ALC. We sought to assess the cost-effectiveness of a nursing home (NH) based TCU leveraging existing infrastructure to support a hospitalized older adult's transition to independent living at home.

METHODS

This case-control study included frail, older adults who received care within a function-focused TCU following a hospitalization between 1 March 2018 and 30 June 2019. TCU patients were propensity score matched to hospitalized ALC patients ("usual care"). The primary outcome was days without requiring institutional care six months following discharge, defined as institutional-free days. This was calculated by excluding all days in hospitals, rehabilitation facilities, complex continuing care facilities and NHs. Using the total direct cost of care up to discharge from TCU or hospital, the incremental cost-effectiveness ratio was calculated.

RESULTS

TCU patients spent, on average, 162.0 days institution-free (95% CI: 156.3-167.6d) within six months days post-discharge, while usual care patients spent 140.6 days institution-free (95% CI: 132.3-148.8d). TCU recipients had a lower total cost of care, by CAN$1,106 (95% CI: $-6,129-$10,319), due to the reduced hospital length of stay (mean [SD] 15.6d [13.3d] for TCU patients and 28.6d [67.4d] days for usual care). TCU was deemed the more cost-effective model of care.

LIMITATIONS

The main limitation was the potential inclusion of patients not eligible for SAFE in our usual group. To minimize this selection bias, we expanded the geographical pool of ALC patients to patients with SAFE admission potential in other area hospitals.

CONCLUSIONS

Through rehabilitative and restorative care, TCUs can reduce hospital length of stay, increase potential for independent living, and reduce risk for subsequent institutionalization.

Measuring the geographic disparity of comorbidity in commercially insured individuals compared to the distribution of physicians in South Africa

Background

Measuring and addressing the disparity between access to healthcare resources and underlying health needs of populations is a prominent focus in health policy development. More recently, the fair distribution of healthcare resources among population subgroups have become an important indication of health inequities. Single disease outcomes are commonly used for healthcare resource allocations; however, leveraging population-level comorbidity measures for health disparity research has been limited. This study compares the geographical distribution of comorbidity and associated healthcare utilization among commercially insured individuals in South Africa (SA) relative to the distribution of physicians.

Methods

A retrospective, cross-sectional analysis was performed comparing the geographical distribution of comorbidity and physicians for 2.6 million commercially insured individuals over 2016–2017, stratified by geographical districts and population groups in SA. We applied the Johns Hopkins ACG® System across the claims data of a large health plan administrator to measure a comorbidity risk score for each individual. By aggregating individual scores, we determined the average healthcare resource need of individuals per district, known as the comorbidity index (CMI), to describe the disease burden per district. Linear regression models were constructed to test the relationship between CMI, age, gender, population group, and population density against physician density.

Results

Our results showed a tendency for physicians to practice in geographic areas with more insurance enrollees and not necessarily where disease burden may be highest. This was confirmed by a negative relationship between physician density and CMI for the overall population and for three of the four major population groups. Among the population groups, the Black African population had, on average, access to fewer physicians per capita than other population groups, before and after adjusting for confounding factors.

Conclusion

CMI is a novel measure for healthcare disparities research that considers both acute and chronic conditions contributing to current and future healthcare costs. Our study linked and compared the population-level geographical distribution of CMI to the distribution of physicians using routinely collected data. Our results could provide vital information towards the more equitable distribution of healthcare providers across population groups in SA, and to meet the healthcare needs of disadvantaged communities.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-022-01899-1.

Multimorbidity Confers Greater Risk for Older Patients in Emergency General Surgery Than the Presence of Multiple Comorbidities: A Retrospective Observational Study

BACKGROUND

Little is known about the impact of multimorbidity on outcomes for older emergency general surgery patients.

OBJECTIVE

The aim was to understand whether having multiple comorbidities confers the same amount of risk as specific combinations of comorbidities (multimorbidity) for a patient undergoing emergency general surgery.

RESEARCH DESIGN

Retrospective observational study using state discharge data.

SUBJECTS

Medicare beneficiaries who underwent an operation for an emergency general surgery condition in New York, Florida, or Pennsylvania (2012-2013).

MEASURES

Patients were classified as multimorbid using Qualifying Comorbidity Sets (QCSs). Outcomes included in-hospital mortality, hospital length of stay and discharge status.

RESULTS

Of 312,160 patients, a large minority (37.4%) were multimorbid. Non-QCS patients did not have a specific combination of comorbidities to satisfy a QCS, but 64.1% of these patients had 3+ comorbid conditions. Multimorbidity was associated with increased in-hospital mortality (10.5% vs. 3.9%, P <0.001), decreased rates of discharge to home (16.2% vs. 37.1%, P <0.001), and longer length of stay (10.4 d±13.5 vs. 6.7 d±9.3, P <0.001) when compared with non-QCS patients. Risks varied between individual QCSs.

CONCLUSIONS

Multimorbidity, defined by satisfying a specific QCS, is strongly associated with poor outcomes for older patients requiring emergency general surgery in the United States. Variation in risk of in-hospital mortality, discharge status, and length of stay between individual QCSs suggests that multimorbidity does not carry the same prognostic weight as having multiple comorbidities-the specifics of which are important in setting expectations for individual, complex patients.

Preventing Multimorbidity with Lifestyle Interventions in Sub-Saharan Africa: A New Challenge for Public Health in Low and Middle-Income Countries

Objectives: Low and Middle-Income Countries are experiencing a fast-paced epidemiological rise in clusters of non-communicable diseases such as diabetes and cardiovascular disease, forming an imminent rise in multimorbidity. However, preventing multimorbidity has received little attention in LMICs, especially in Sub-Saharan African Countries. Methods: Narrative review which scoped the most recent evidence in LMICs about multimorbidity determinants and appropriated them for potential multimorbidity prevention strategies. Results: MMD in LMICs is affected by several determinants including increased age, female sex, environment, lower socio-economic status, obesity, and lifestyle behaviours, especially poor nutrition, and physical inactivity. Multimorbidity public health interventions in LMICs, especially in Sub-Saharan Africa are currently impeded by local and regional economic disparity, underdeveloped healthcare systems, and concurrent prevalence of communicable and non-communicable diseases. However, lifestyle interventions that are targeted towards preventing highly prevalent multimorbidity clusters, especially hypertension, diabetes, and cardiovascular disease, can provide early prevention of multimorbidity, especially within Sub-Saharan African countries with emerging economies and socio-economic disparity. Conclusion: Future public health initiatives should consider targeted lifestyle interventions and appropriate policies and guidelines in preventing multimorbidity in LMICs.

The prevalence of multimorbidity and its association with physical activity and sleep duration in middle aged and elderly adults: a longitudinal analysis from China

Background

Preventing chronic disease is important in health policy in countries with significantly ageing populations. This study aims to examine the prevalence of chronic disease multimorbidity and its association with physical activity and sleep duration; and to understand whether physical activity modifies associations between sleep duration and multimorbidity.

Methods

We utilized longitudinal data of a nationally-representative sample from the China Health and Retirement Longitudinal Study (in year 2011 and 2015; N = 5321; 54.7% female; age ≥ 45 years old). Fourteen chronic diseases were used to measure multimorbidity (ten self-reported, and four by blood test). Participants were grouped into high, moderate, and low level based on self-reported frequencies and durations of physical activity with different intensities for at least 10 min at a time in a usual week. Poor and good sleepers were categorized according to average hours of actual sleep at each night during the past month. Panel data method of random-effects logistic regression model was applied to estimate the association of physical activity and sleep with multimorbidity, adjusting for social-demographic and behavioural confounders.

Results

From 2011 to 2015, the prevalence of multimorbidity increased from 52.2 to 62.8%. In 2015, the proportion of participants engaging in high, moderate, and low level of physical activity was 30.3, 24.4 and 45.3%, respectively, and 63.6% of adults had good sleep. For both genders, compared with good sleep, poor sleep was associated with higher odds of multimorbidity (OR = 1.527, 95% CI: 1.277, 1.825). Compared to the high-level group, participants with a low level of physical activity were significantly more likely to have multimorbidity (OR = 1.457, 95% CI: 1.277, 1.825), but associations were stronger among women. The relative excess risk due to interaction between poor sleep and moderate or low physical activity was positive but non-significant on multimorbidity.

Conclusions

The burden of multimorbidity was high in China. Low physical activity and poor sleep was independently and significantly associated with a higher likelihood of multimorbidity in women and both genders, separately. Physical activity could modify the association between sleep and multimorbidity.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12966-021-01150-7.

The impact of mental and physical multimorbidity on healthcare utilization and health spending in China: A nationwide longitudinal population-based study

BACKGROUND

In China, little evidence exists on the effect of mental and physical multimorbidity on individuals and the health system. This study aims to examine the prevalence of mental-physical multimorbidity and its impact on health service utilization and health expenditures.

METHODS

We conducted a panel study using two waves of data (in 2011 and 2015) from the China Health and Retirement Longitudinal Study, including 10,181 participants aged 45 years and older. Generalized linear regression models were used to assess the association of multimorbidity with total health expenditure and out-of-pocket expenditure (OOPE) on outpatient and inpatient care. Random-effects logistic regression models were used to examine the impact of multimorbidity on outpatient visits, admission to hospital and incidence of catastrophic health expenditure (CHE).

RESULTS

Overall, 3210 participants (31.53% of 10,181) had mental-physical multimorbidity in 2015 in China. Compared to patients with a single physical disease, individuals with physical-mental multimorbidity had over 150% of the increase in the number of outpatient visits and days of hospitalization. The percentage change of OOPE for outpatient and inpatient care was 156.8% and 163.6%, respectively. Mental-physical multimorbidity was associated with an increased likelihood of experiencing CHE (OR = 2.205, 95% CI = 2.048, 2.051).

CONCLUSION

Multimorbidity, particularly mental-physical multimorbidity, is associated with higher levels of health service use and a greater financial burden to individuals in China. Healthcare system needs to shift from single-disease models to new financing and service delivery models to more effectively manage mental-physical multimorbidity.

Discrimination and Multimorbidity Among Black Americans: Findings from the National Survey of American Life

OBJECTIVES

There is a notable lack of research on the risk factors for multimorbidity, which has become more common over recent decades. Black Americans experience discrimination more often than their White counterparts, and also have significantly higher prevalence of multimorbidity. This paper examines the associations between discrimination and multimorbidity among Black Americans.

METHODS

We analyzed data from the National Survey of American Life to calculate the prevalence of two types of discrimination (everyday discrimination, major discriminatory events) and multimorbidity (physical, psychiatric, mixed, any). Using multivariable logistic regression, we examined the associations between discrimination and multimorbidity, adjusting for age, sex, years of education, income-to-poverty ratio, and ethnicity. The everyday discrimination scale was discretized into five categories (none, low, medium, high, very high), but was also treated as a continuous variable. The major discriminatory events were analyzed in separate adjusted models, and as a count of events.

RESULTS

When compared with those who did not experience any discrimination, people who experienced everyday discrimination were significantly more likely to report all types of multimorbidity in a dose-response fashion at a conventional level of statistical significance. Most major discriminatory events were associated with greater odds of reporting all types of multimorbidity, as were the counts of major discriminatory events, in a dose-response fashion.

CONCLUSIONS

We found strong evidence to suggest that discrimination was associated with greater odds of reporting multimorbidity. Future studies can expand on these findings using longitudinal data to capture the relations between discrimination and health over time, or by testing preventive interventions that allay the damaging health effects of discrimination.

Epidemiology of thyroid disorders in the Lifelines Cohort Study (the Netherlands)

BACKGROUND

Thyroid hormone plays a pivotal role in human metabolism. In epidemiologic studies, adequate registration of thyroid disorders is warranted. We examined the prevalence of thyroid disorders, reported thyroid medication use, thyroid hormone levels, and validity of thyroid data obtained from questionnaires in the Lifelines Cohort Study.

METHODS

We evaluated baseline data of all 152180 subjects (aged 18-93 years) of the Lifelines Cohort Study. At baseline, participants were asked about previous thyroid surgery and current and previous thyroid hormone use. At follow-up (n = 136776, after median 43 months), incident thyroid disorders could be reported in an open, non-structured question. Data on baseline thyroid hormone measurements (TSH, FT4 and FT3) were available in a subset of 39935 participants.

RESULTS

Of the 152180 participants, mean (±SD) age was 44.6±13.1 years and 58.5% were female. Thyroid medication was used by 4790 participants (3.1%); the majority (98.2%) used levothyroxine, and 88% were females. 59.3% of levothyroxine users had normal TSH levels. The prevalence of abnormal TSH levels in those not using thyroid medication was 10.8%; 9.4% had a mildly elevated (4.01-10.0 mIU/L), 0.7% had suppressed (<0.40 mIU/L), while 0.7% had elevated (>10.0 mIU/L) TSH levels. Over 98% of subjects with TSH between 4 and 10 mIU/L had normal FT4. Open text questions allowing to report previous thyroid surgery and incident thyroid disorders proved not to be reliable and severely underestimated the true incidence and prevalence of thyroid disorders.

CONCLUSIONS

Undetected thyroid disorders were prevalent in the general population, whereas the prevalence of thyroid medication use was 3.1%. Less than 60% of individuals using levothyroxine had a normal TSH level. The large group of individuals with subclinical hypothyroidism (9.4%) offers an excellent possibility to prospectively follow the natural course of this disorder. Both structured questions as well as linking to G.P.'s and pharmacists' data are necessary to improve the completeness and reliability of Lifelines' data on thyroid disorders.

Assessing the geographical distribution of comorbidity among commercially insured individuals in South Africa

BACKGROUND

Comorbidities are strong predictors of current and future healthcare needs and costs; however, comorbidities are not evenly distributed geographically. A growing need has emerged for comorbidity surveillance that can inform decision-making. Comorbidity-derived risk scores are increasingly being used as valuable measures of individual health to describe and explain disease burden in populations.

METHODS

This study assessed the geographical distribution of comorbidity and its associated financial implications among commercially insured individuals in South Africa (SA). A retrospective, cross-sectional analysis was performed comparing the geographical distribution of comorbidities for 2.6 million commercially insured individuals over 2016-2017, stratified by geographical districts in SA. We applied the Johns Hopkins ACG® System across the insurance claims data of a large health plan administrator in SA to measure comorbidity as a risk score for each individual. We aggregated individual risk scores to determine the average risk score per district, also known as the comorbidity index (CMI), to describe the overall disease burden of each district.

RESULTS

We observed consistently high CMI scores in districts of the Free State and KwaZulu-Natal provinces for all population groups before and after age adjustment. Some areas exhibited almost 30% higher healthcare utilization after age adjustment. Districts in the Northern Cape and Limpopo provinces had the lowest CMI scores with 40% lower than expected healthcare utilization in some areas after age adjustment.

CONCLUSIONS

Our results show underlying disparities in CMI at national, provincial, and district levels. Use of geo-level CMI scores, along with other social data affecting health outcomes, can enable public health departments to improve the management of disease burdens locally and nationally. Our results could also improve the identification of underserved individuals, hence bridging the gap between public health and population health management efforts.

Cannabis use, other drug use, and risk of subsequent acute care in primary care patients

BACKGROUND

Cannabis and other drug use is associated with adverse health events, but little is known about the association of routine clinical screening for cannabis or other drug use and acute care utilization. This study evaluated whether self-reported frequency of cannabis or other drug use was associated with subsequent acute care.

METHOD

This retrospective cohort study used EHR and claims data from 8 sites in Washington State that implemented annual substance use screening. Eligible adult primary care patients (N = 47,447) completed screens for cannabis (N = 45,647) and/or other drug use, including illegal drug use and prescription medication misuse, (N = 45,255) from 3/3/15-10/1/2016. Separate single-item screens assessed frequency of past-year cannabis and other drug use: never, less than monthly, monthly, weekly, daily/almost daily. An indicator of acute care utilization measured any urgent care, emergency department visits, or hospitalizations ≤19 months after screening. Adjusted Cox proportional hazards models estimated risk of acute care.

RESULTS

Patients were predominantly non-Hispanic White. Those reporting cannabis use less than monthly (Hazard Ratio [HR] = 1.12, 95 % CI = 1.03-1.21) or daily (HR = 1.24; 1.10-1.39) had greater risk of acute care during follow-up than those reporting no use. Patients reporting other drug use less than monthly (HR = 1.34; 1.13-1.59), weekly (HR = 2.21; 1.46-3.35), or daily (HR = 2.53; 1.86-3.45) had greater risk of acute care than those reporting no other drug use.

CONCLUSION

Population-based screening for cannabis and other drug use in primary care may have utility for understanding risk of subsequent acute care. It is unclear whether findings will generalize to U.S. states with broader racial/ethnic diversity.

Chronic kidney disease in the context of multimorbidity patterns: the role of physical performance : The screening for CKD among older people across Europe (SCOPE) study

Background

Chronic kidney disease (CKD) is known to be associated with several co-occurring conditions. We aimed at exploring multimorbidity patterns associated with CKD, as well as the impact of physical performance and CKD severity on them in a population of older outpatients.

Methods

Our series consisted of 2252 patients enrolled in the Screening of CKD among Older People across Europe multicenter observational study. Hypertension, stroke, transient ischemic attack, cancer, hip fracture, osteoporosis, Parkinson’s disease, asthma, chronic obstructive pulmonary disease, congestive heart failure, angina, myocardial infarction, atrial fibrillation, anemia, CKD (defined as GFR < 60, < 45 or < 30 ml/min/1.73 m²), cognitive impairment, depression, hearing impairment and vision impairment were included in the analyses. Physical performance was assessed by the Short Physical Performance Battery (SPPB) and used as stratification variable. Pairs of co-occurring diseases were analyzed by logistic regression. Patterns of multimorbidity were investigated by hierarchical cluster analysis.

Results

CKD was among the most frequently observed conditions and it was rarely observed without any other co-occurring disease. CKD was significantly associated with hypertension, anemia, heart failure, atrial fibrillation, myocardial infarction and hip fracture. When stratifying by SPPB, CKD was also significantly associated with vision impairment in SPPB = 5–8 group, and hearing impairment in SPPB = 0–4 group. Cluster analysis individuated two main clusters, one including CKD, hypertension and sensory impairments, and the second including all other conditions. Stratifying by SPPB, CKD contribute to a cluster including diabetes, anemia, osteoporosis, hypertension and sensory impairments in the SPPB = 0–4 group. When defining CKD as eGFR< 45 or 30 ml/min/1.73 m², the strength of the association of CKD with hypertension, sensory impairments, osteoporosis, anemia and CHF increased together with CKD severity in pairs analysis. Severe CKD (eGFR< 30 ml/min/1.73 m²) contributed to a wide cluster including cardiovascular, respiratory and neurologic diseases, as well as osteoporosis, hip fracture and cancer.

Conclusions

CKD and its severity may contribute significantly to specific multimorbidity patterns, at least based on the cluster analysis. Physical performance as assessed by SPPB may be associated with not negligible changes in both co-occurring pairs and multimorbidity clusters.

Trial registration

The SCOPE study is registered at clinicaltrials.gov (NCT02691546).

Comparing Childhood Cancer Care Costs in Two Canadian Provinces

Background:

Cancer in children presents unique issues for diagnosis, treatment and survivorship care. Phase-specific comparative cost estimates are important for informing healthcare planning.

Objectives:

The aim of this paper is to compare direct medical costs of childhood cancer by phase of care in British Columbia (BC) and Ontario (ON).

Methods:

For cancer patients diagnosed at <15 years of age and propensity-score-matched non-cancer controls, we applied standard costing methodology using population-based healthcare administrative data to estimate and compare phase-based costs by province.

Results:

Phase-specific cancer-attributable costs were 2%–39% higher for ON than for BC. Leukemia pre-diagnosis costs and annual lymphoma continuing care costs were >50% higher in ON. Phase-specific in-patient hospital costs (the major cost category) represented 63%–82% of ON costs, versus 43%–73% of BC costs. Phase-specific diagnostic tests and procedures accounted for 1.0%–3.4% of ON costs and 2.8%–13.0% of BC costs.

Conclusions:

There are substantial cost differences between these two Canadian provinces, BC and ON, possibly identifying opportunities for healthcare planning improvement.

Prevalence and treatment of opioid use disorders among primary care patients in six health systems

BACKGROUND

The U.S. experienced nearly 48,000 opioid overdose deaths in 2017. Treatment of opioid use disorder (OUD) with buprenorphine is a recommended part of primary care, yet little is known about current U.S. practices in this setting. This observational study reports the prevalence of documented OUD and OUD treatment with buprenorphine among primary care patients in six large health systems.

METHODS

Adults with ≥2 primary care visits during a three-year period (10/1/2013-9/30/2016) in six health systems were included. Data were obtained from electronic health record and claims data, with measures, assessed over the three-year period, including indicators for documented OUD from ICD 9 and 10 codes and OUD treatment with buprenorphine. The prevalence of OUD treatment was adjusted for age, gender, race/ethnicity, and health system.

RESULTS

Among 1,368,604 primary care patients, 13,942 (1.0 %) had documented OUD, and among these, 21.0 % had OUD treatment with buprenorphine. For those with documented OUD, the adjusted prevalence of OUD treatment with buprenorphine varied across demographic and clinical subgroups. OUD treatment was lower among patients who were older, women, Black/African American and Hispanic (compared to white), non-commercially insured, and those with non-cancer pain, mental health disorders, greater comorbidity, and more opioid prescriptions, emergency department visits or hospitalizations.

CONCLUSIONS

Among primary care patients in six health systems, one in five with an OUD were treated with buprenorphine, with disparities across demographic and clinical characteristics. Less buprenorphine treatment among those with greater acute care utilization highlights an opportunity for systems-level changes to increase OUD treatment.

Direct cost of Parkinson's disease in a health system with high judicialization: evidence from Colombia

Objective: To estimate all-claims-all-conditions expenditures paid for by health plans for patients suffering from Parkinson´s disease (PD). Methods: Using administrative claims data from two health maintenance organizations for 2014 and 2015 in Colombia, we identified 2,917 patients with PD by applying an algorithm that uses International Statistical Classification of Diseases and Related Health Problems and Anatomical Therapeutic Chemical Classification System codes. Descriptive statistics were applied to compute unadjusted all-cause median costs. A generalized linear model was used to estimate adjusted and attributable direct costs of advanced PD. Results: Approximately 30% of the all-cause direct costs were associated with technologies not included in universal health coverage benefit packages. In 2015, the annual median interquartile range per patient all-cause direct costs to insurers was USD1,576 (605-3,617). About 16% of patients had advanced PD. Regression analysis estimated that additional costs attributable to advanced PD was USD3,416 (p = 0.000). Multimorbidity was highly prevalent, and 96% of PD patients had at least one other chronic condition. Conclusions: In the context of high judicialization, patients suffering from PD must increasingly use the judicial system to access treatment. To promote more equitable and efficient access benefit packages, developing countries must consider more thoroughly the needs of these patients.

Prevalence of chronic liver disease among young/middle-aged adults in Northern Italy: role of hepatitis B and hepatitis C virus infection by age, sex, ethnicity

Background

Sparse population-based data are available on the prevalence and etiology of chronic liver disease (CLD) in Italy. The study aims to assess the role of hepatitis B virus (HBV) and hepatitis C virus (HCV) infection in CLD according to age, gender and ethnicity.

Methods

Clinically diagnosed CLD in the general population aged 20–59 years in the Veneto Region (North-Eastern Italy) were identified through the Adjusted Clinical Groups System, by record linkage of the archive of subjects enrolled in the Regional Health System with Hospital Discharge Records, Emergency Room visits, Chronic disease registry for copayment exemptions, and the Home care database. Age-standardized prevalence rates (PR) were computed in Italians and immigrants, based on country of citizenship.

Results

Overall 22,934 subjects affected by CLD in 2016 were retrieved, 21% related to HBV and 43% to HCV infection. The prevalence of HCV-related CLD was higher in males, peaking at 50–54 years (males = 11/1000; females = 4/1000). The PR of HBV-related CLD was almost negligible in the Italian population (1/1000), and higher among immigrants, especially from East Asia (males = 17/1000; females = 11/1000) and Sub-Saharan Africa (males = 13/1000; females = 10/1000).

Conclusion

Specific population sub-groups identified by age, gender, and ethnicity, were demonstrated to be at increased risk, and these trends are in line with global epidemiological patterns of viral hepatitis.

Direct cost of lupus care in the developing world: the case of Colombia

Background

Lupus is a chronic autoimmune and incurable rheumatic disease and has a global prevalence of 3.2–517.5 cases per 100,000 people. However, currently there is no knowledge regarding the actual direct cost of patients with lupus to healthcare systems in developing countries. This study aimed to determine the direct cost of lupus care in Colombia.

Methods

To identify patients with lupus, claims data of 2 years from two health insurers were subjected to an algorithm according to International Statistical Classification of Diseases and Related Health Problems 10th Revision codes. Multivariate linear regression analyses were used to assess the direct cost of lupus care.

Results

The average annual per-patient, all-claims, all-cause direct cost was $2355; this is approximately 9 times the average annual premium received by health insurers for covering the public benefits package. Approximately 50% of direct costs are not included in the public benefits package. The incidence of one or more condition is 98.4%. The direct cost incurred by patients with two comorbidities was 1.8 times more, with three chronic conditions was 1.9 times more and with six chronic conditions was 4.5 times more than that incurred by patients with only lupus.

Conclusions

The direct cost of lupus care in the developing world may be higher than expected; in addition, access to healthcare may not be equal for the entire population.

Development and Assessment of a Crosswalk Between ICD-9-CM and ICD-10-CM to Identify Patients with Common Pain Conditions

Effective management of patients with pain requires accurate information about the prevalence, outcomes, and co-occurrence of common pain conditions. However, the transition from ICD-9-CM to ICD-10-CM diagnostic coding in 2015 left researchers without methods for comparing the prevalence of pain conditions before and after the transition. In this study, we developed and assessed a diagnostic framework to serve as a crosswalk between ICD-9-CM and ICD-10-CM diagnosis codes for common pain-related health conditions. We refined existing ICD-9-CM definitions for diagnostic clusters of common pain conditions consistent with the US National Pain Strategy and developed corresponding ICD-10-CM definitions. We then assessed the stability of prevalence estimates and associated patient socio-demographic features of each diagnostic cluster during 1-year periods before and after the transition to ICD-10-CM in 3 US health care systems using electronic health records data for in-person encounters. Prevalence estimates and socio-demographic characteristics were similar before and after the transition. The Pain Condition ICD-9-CM to ICD-10-CM Crosswalk includes a full spectrum of common pain conditions to enable prevalence estimates of multiple and chronic overlapping pain conditions. This allows the tool to serve as a foundation for a broad array of pain-related health services research utilizing electronic databases. PERSPECTIVE: This article details the development and assessment of the Pain Condition ICD-9-CM to ICD-10-CM Crosswalk, a diagnostic framework for assessing pain condition prevalence across the ICD-9-CM to ICD-10-CM transition. This framework can serve as a standardized tool for research on pain conditions, including health services and epidemiologic research.

Defining Multimorbidity in Older Surgical Patients

BACKGROUND

There are numerous definitions of multimorbidity (MM). None systematically examines specific comorbidity combinations accounting for multiple testing when exploring large datasets.

OBJECTIVES

Develop and validate a list of all single, double, and triple comorbidity combinations, with each individual qualifying comorbidity set (QCS) more than doubling the odds of mortality versus its reference population. Patients with at least 1 QCS were defined as having MM.

RESEARCH DESIGN

Cohort-based study with a matching validation study.

SUBJECTS

All fee-for-service Medicare patients between age 65 and 85 without dementia or metastatic solid tumors undergoing general surgery in 2009-2010, and an additional 2011-2013 dataset.

MEASURES

30-day all-location mortality.

RESULTS

There were 576 QCSs (2 singles, 63 doubles, and 511 triples), each set more than doubling the odds of dying. In 2011, 36% of eligible patients had MM. As a group, multimorbid patients (mortality rate=7.0%) had a mortality Mantel-Haenszel odds ratio=1.90 (1.77-2.04) versus a reference that included both multimorbid and nonmultimorbid patients (mortality rate=3.3%), and Mantel-Haenszel odds ratio=3.72 (3.51-3.94) versus only nonmultimorbid patients (mortality rate=1.6%). When matching 3151 pairs of multimorbid patients from low-volume hospitals to similar patients in high-volume hospitals, the mortality rates were 6.7% versus 5.2%, respectively (P=0.006).

CONCLUSIONS

A list of QCSs identified a third of older patients undergoing general surgery that had greatly elevated mortality. These sets can be used to identify vulnerable patients and the specific combinations of comorbidities that make them susceptible to poor outcomes.

Multimorbidity in middle age predicts more subsequent hospital admissions than in older age: A nine-year retrospective cohort study of 121,188 discharged in-patients

BACKGROUND

Previous research has suggested a differential short-term effect of multimorbidity on hospitalization by age, with younger groups affected more. This study compares the nine-year hospitalization pattern by age and multimorbidity status in a retrospective cohort of discharged in-patients, who represent a high-need portion of the population.

METHODS

We examined routine clinical records of all patients aged 45+ years with chronic conditions discharged from public general hospitals in 2005 in Hong Kong. Patterns of annual frequencies of hospital admissions and number of hospitalized days over nine years (2005-2014) were compared by multimorbidity status (1, 2, 3+ conditions) and age group (45-64, 65-74, 75+).

RESULTS

Among 121,188 included patients, 33.9% had 2+ conditions and 12.3% had 3+. Hospitalization patterns varied by age and multimorbidity status. For those having only 1 condition, annual number of admissions was similar by age, but older patients had more hospitalized days (4.40 days per person-year for the 45-64 group versus 10.29 for the 75+ group in the 5th year). For those with 3+ conditions, younger patients had more admissions (4.39 admissions per person-year for the 45-64 group versus 1.87 for the 75+ group in the 5th year) but similar number of hospitalized days with older patients. Interaction analysis showed effect of multimorbidity on hospitalization was stronger in younger groups (P < 0.05).

CONCLUSION

Middle-aged discharged in-patients with multimorbidity are admitted more often than their older counterparts and have similar total hospitalized days per year. Further research is needed to investigate chronic care needs of younger people with multimorbidity.

Multimorbidity patterns in high-need, high-cost elderly patients

Introduction

Patients with complex health care needs (PCHCN) are individuals who require numerous, costly care services and have been shown to place a heavy burden on health care resources. It has been argued that an important issue in providing value-based primary care concerns how to identify groups of patients with similar needs (who pose similar challenges) so that care teams and care delivery processes can be tailored to each patient subgroup. Our study aims to describe the most common chronic conditions and their combinations in a cohort of elderly PCHCN.

Methods

We focused on a cohort of PCHCN residing in an area served by a local public health unit (the “Azienda ULSS4-Veneto”) and belonging to Resource Utilization Bands 4 and 5 according to the ACG System. For each patient we extracted Expanded Diagnosis Clusters, and combined them with information available from Rx-MGs diagnoses. For the present work we focused on 15 diseases/disorders, analyzing their combinations as dyads and triads. Latent class analysis was used to elucidate the patterns of the morbidities considered in the PCHCN.

Results

Five disease clusters were identified: one concerned metabolic-ischemic heart diseases; one was labelled as neurological and mental disorders; one mainly comprised cardiac diseases such as congestive heart failure and atrial fibrillation; one was largely associated with respiratory conditions; and one involved neoplasms.

Conclusions

Our study showed specific common associations between certain chronic diseases, shedding light on the patterns of multimorbidity often seen in PCHCN. Studying these patterns in more depth may help to better organize the intervention needed to deal with these patients.

Impact of heart failure and other comorbidities on mortality in patients with chronic obstructive pulmonary disease: a register-based, prospective cohort study

BACKGROUND

Multimorbidity has already become common in primary care and will be a challenge in the future. Primary care in Sweden participates to a great extent in the care of patients with two severe, chronic conditions: chronic obstructive pulmonary disease (COPD) and heart failure. Both conditions are characterized by high mortality and often coexist. Age, sex, heart failure and other comorbidities are considered to be the major predictors of mortality in patients with COPD. We aimed to study the impact of heart failure, other comorbidities, age and sex on mortality in patients with COPD.

METHODS

A register-based, prospective cohort study conducted in Blekinge County in Sweden with about 150,000 inhabitants. The study population was comprised of people aged ≥35 years. The data about diagnoses of COPD and heart failure came from the 2007 health care register, in which we found 984 individuals with a diagnosis of COPD. Date of death was collected from January 1st, 2008 -August 31st, 2015. The diagnosis-based Adjusted Clinical Groups (ACG) Case-Mix System 7.1 was used to describe comorbidity. Each individual was assigned one of six comorbidity levels called resource utilization bands (RUB) graded from 0 to 5.

RESULTS

Estimated eight year mortality in patients with COPD and coexisting heart failure was seven times higher than in patients with COPD alone - odds ratio 7.06 (95% CI 3.88-12.84). Adjusting for age and male sex resulted in odds ratio 3.75 (95% CI 1.97-7.15). Further adjusting for other comorbidities resulted in odds ratio 3.26 (95% CI 1.70-6.25). The mortality was strongly associated with the highest comorbidity level - RUB 5 where the odds ratio was 5.19 (95% CI 2.59-10.38).

CONCLUSION

Heart failure has an important impact on mortality in patients with COPD. The mortality in patients with COPD and coexisting heart failure was strongly associated with age, male sex and other comorbidities. Of those three predictors, only other comorbidities can be influenced. Heart failure and other comorbidities should be recognized early and properly treated in order to improve survival in patients with coexisting COPD and heart failure.

From wholes to fragments to wholes-what gets lost in translation?

The highly demanding and, in a certain sense, unique, working conditions of general practitioners (GPs) are characterized by two phenomena: First, they involve an increasing familiarity with individual patients over time, which promotes a deepening of insight. Second, they enable the GP to encounter all kinds of health problems, which in turn facilitates pattern recognition, at both individual and group levels, particularly the kind of patterns currently termed "multimorbidity." Whereas the term "comorbidity" is used to denote states of bad health in which 1 disease is considered to predate and evoke other ailments or diseases, the term multimorbidity is applied when finding several presumably separate diseases in a person who suffers from them either sequentially or simultaneously. Encounters with patients whose suffering fits the biomedical concept and terminology of multimorbidity are among the most common which GPs face, presenting them with some of their most demanding tasks. The term multimorbidity needs to be examined, however. As it alludes to a multiplicity of diseases, it rests on an assumption of separateness of states of bad health that might not be well founded. An adequate determination of what to deem a "separate" state of bad health would require that the biomedical concept of causation be scrutinized.

Active listing and more consultations in primary care are associated with shorter mean hospitalisation and interacting with psychiatric disorders when adjusting for multimorbidity, age and sex

OBJECTIVE

Patient-provider relationships with primary care and need for hospitalisations are related within the complex networks comprising healthcare. Our objective was to analyse mean days hospitalised, using registration status (active or passive listing) with a provider and number of consultations as proxies of patient-provider relationships with primary care, adjusting for morbidity burden, age and sex while analysing the contribution of psychiatric disorders. The Johns Hopkins Adjusted Clinical Groups Case-Mix System was used to classify morbidity burden into Resource Utilization Band (RUB) 0-5.

DESIGN

Cross-sectional population study using zero-inflated negative binomial regression.

SETTING AND SUBJECTS

All population in the Swedish County of Blekinge (N = 151 731) in 2007.

MAIN OUTCOME MEASURE

Mean days hospitalised.

RESULTS

Actively listed were in mean hospitalised for 0.86 (95%CI 0.81-0.92) and passively listed for 1.23 (95%CI 1.09-1.37) days. For 0-1 consultation mean days hospitalised was 1.16 (95%CI 1.08-1.23) and for 4-5 consultations 0.68 (95%CI 0.62-0.75) days. At RUB3, actively listed were in mean hospitalised for 3.45 (95%CI 2.84-4.07) days if diagnosed with any psychiatric disorder and 1.64 (95%CI 1.50-1.77) days if not. Passively listed at RUB3 were in mean hospitalised for 5.17 (95%CI 4.36-5.98) days if diagnosed with any psychiatric disorder and 2.41 (95%CI 2.22-2.60) days if not.

CONCLUSIONS

Active listing and more consultations were associated with a decrease in mean days hospitalised, especially for patients with psychiatric diagnoses.

IMPLICATIONS

Promoting good relationships with primary care could be an opportunity to decrease mean days hospitalised, especially for patients with more complex diagnostic patterns. Key Points Primary care performance, patient-provider relationships and need for hospitalisation are related within the complex networks comprising healthcare systems. Good patient-provider relationships, i.e. more consultations and active listing, with primary care are associated with decreasing mean days hospitalised. The impact of patient-provider relationships in primary care on mean days hospitalised increased when psychiatric disorders added to patient complexity.

A case-mix classification system for explaining healthcare costs using administrative data in Italy

BACKGROUND

The Italian National Health Service (NHS) provides universal coverage to all citizens, granting primary and hospital care with a copayment system for outpatient and drug services. Financing of Local Health Trusts (LHTs) is based on a capitation system adjusted only for age, gender and area of residence. We applied a risk-adjustment system (Johns Hopkins Adjusted Clinical Groups System, ACG® System) in order to explain health care costs using routinely collected administrative data in the Veneto Region (North-eastern Italy).

METHODS

All residents in the Veneto Region were included in the study. The ACG system was applied to classify the regional population based on the following information sources for the year 2015: Hospital Discharges, Emergency Room visits, Chronic disease registry for copayment exemptions, ambulatory visits, medications, the Home care database, and drug prescriptions. Simple linear regressions were used to contrast an age-gender model to models incorporating more comprehensive risk measures aimed at predicting health care costs.

RESULTS

A simple age-gender model explained only 8% of the variance of 2015 total costs. Adding diagnoses-related variables provided a 23% increase, while pharmacy based variables provided an additional 17% increase in explained variance. The adjusted R-squared of the comprehensive model was 6 times that of the simple age-gender model.

CONCLUSIONS

ACG System provides substantial improvement in predicting health care costs when compared to simple age-gender adjustments. Aging itself is not the main determinant of the increase of health care costs, which is better explained by the accumulation of chronic conditions and the resulting multimorbidity.

Active listing and more consultations in primary care are associated with reduced hospitalisation in a Swedish population

BACKGROUND

Healthcare systems are complex networks where relationships affect outcomes. The importance of primary care increases while health care acknowledges multimorbidity, the impact of combinations of different diseases in one person. Active listing and consultations in primary care could be used as proxies of the relationships between patients and primary care. Our objective was to study hospitalisation as an outcome of primary care, exploring the associations with active listing, number of consultations in primary care and two groups of practices, while taking socioeconomic status and morbidity burden into account.

METHODS

A cross-sectional study using zero-inflated negative binomial regression to estimate odds of any hospital admission and mean number of days hospitalised for the population over 15 years (N = 123,168) in the Swedish county of Blekinge during 2007. Explanatory factors were listed as active or passive in primary care, number of consultations in primary care and primary care practices grouped according to ownership. The models were adjusted for sex, age, disposable income, education level and multimorbidity level.

RESULTS

Mean days hospitalised was 0.94 (95%CI 0.90-0.99) for actively listed and 1.32 (95%CI 1.24-1.40) for passively listed. For patients with 0-1 consultation in primary care mean days hospitalised was 1.21 (95%CI 1.13-1.29) compared to 0.77 (95%CI 0.66-0.87) days for patients with 6-7 consultations. Mean days hospitalised was 1.22 (95%CI 1.16-1.28) for listed in private primary care and 0.98 (95%CI 0.94-1.01) for listed in public primary care, with odds for hospital admission 0.51 (95%CI 0.39-0.63) for public primary care compared to private primary care.

CONCLUSIONS

Active listing and more consultations in primary care are both associated with reduced mean days hospitalised, when adjusting for socioeconomic status and multimorbidity level. Different odds of any hospitalisation give a difference in mean days hospitalised associated with type of primary care practice. To promote well performing primary care to maintain good relationships with patients could reduce mean days hospitalised.

Diverging patterns of cardiovascular diseases across immigrant groups in Northern Italy

BACKGROUND

Only fragmentary data are available on the burden of non-communicable diseases among immigrants in Europe, mostly limited to mortality by cause. Aim of the study is to investigate the prevalence of cardiovascular diseases across different immigrant groups in the Veneto Region (North-Eastern Italy).

METHODS

The resident population aged 20-59 was classified according to country of citizenship. The Adjusted Clinical Groups System was adopted to identify selected cardiovascular conditions by linkage of Hospital Discharge Records, Emergency Room visits, Chronic disease registry for copayment exemptions, the Home care database, and drugs reimbursed by the Regional Health Service. Age standardized prevalence rates were compared across population groups, and rate ratios (RR) with 95% confidence intervals (CI) were computed taking the Italian population as reference.

RESULTS

The prevalence of diabetes was higher across all immigrant groups compared to Italians. Specific risk patterns could be identified associated to different ethnicities: South Asian immigrants were at very high risk of diabetes, dyslipidemia, and ischemic heart disease (males RR 2.3, CI 1.9-2.8; females RR 2.0, CI 1.2-3.5). Immigrants from Africa were affected by high rates of hypertension, cerebrovascular diseases, and heart failure, with a more pronounced unfavorable profile among females (hypertension RR 3.0, CI 2.6-3.3; cerebrovascular diseases RR 1.7, CI 1.1-2.7).

CONCLUSIONS

Wide differences in the prevalence of cardiovascular diseases could be detected across immigrant groups. These findings represent a first step towards systematic chronic disease surveillance by ethnicity, a fundamental tool for shaping culturally-tailored prevention strategies.

Epidemiological trends and direct costs of diabetes in a Northern Italy area: 2012 health administrative records analysis LHT n. 20 Verona

OBJECTIVE

This analysis estimates type 1 and type 2 diabetes direct costs in 2012, in terms of hospital care, outpatient visits, diagnostics and medications, in a local healthcare trust in Northern Italy (ULSS n.20 Verona).

METHODS

The Johns Hopkins Adjusted Clinical Group (ACG^®) System was used to analyze data, including hospital discharges, emergency room admissions, medical encounter records, disease registries, copayment exemptions, home care services, psychiatric services, rehabilitation services, and medications. Data from general practitioners and nursing homes were not directly available. Patients obtained from the first analysis were subsequently divided in two groups (type 1 and type 2 diabetes) according to ATC drug classification system and age. Costs were estimated from inpatient and outpatients fees and drugs costs.

RESULTS

ULSS n. 20 takes care of about 480.000 people. We identified 974 people affected by type 1 diabetes (prevalence 0,2%) and 24.087 people affected by type 2 diabetes (prevalence 5,0%) among the residents in 2012. Hospitalization mean annual cost was 4.753,50€ (SD 9.330,19€) for type 1 diabetes and 1.718,08€ (SD 5.087,34€) for type 2 diabetes. Outpatient care mean annual cost was 1.401,76€ (SD 4.394,88€) for type 1 diabetes and 669,15€ (SD 2.121,24€) for type 2 diabetes. Medications mean annual cost was 1,369,35€ (SD1.781,18€) for type 1 diabetes and 874,07€ (SD 2.832,2€) for type 2 diabetes.

CONCLUSIONS

ACG^® diabetes data analysis agrees with data obtained by more expensive methods and seems to be a comprehensive and applicable tool to analyze chronic diseases dynamics in the Italian setting in order to prioritize future research and analyze the effects of interventions aimed to ensure the sustainability of public health services. Because of the combination between prevalence data and epidemiological trends, we could be at the eve of a dramatic increase of diabetes costs with major concerns for the Italian NHS ability to withstand.

Living In A Country With A Strong Primary Care System Is Beneficial To People With Chronic Conditions

In light of the growing pressure that multiple chronic diseases place on health care systems, we investigated whether strong primary care was associated with improved health outcomes for the chronically ill. We did this by combining country- and individual-level data for the twenty-seven countries of the European Union, focusing on people's self-rated health status and whether or not they had severe limitations or untreated conditions. We found that people with chronic conditions were more likely to be in good or very good health in countries that had a stronger primary care structure and better coordination of care. People with more than two chronic conditions benefited most: Their self-rated health was higher if they lived in countries with a stronger primary care structure, better continuity of care, and a more comprehensive package of primary care services. In general, while having access to a strong primary care system mattered for people with chronic conditions, the degree to which it mattered differed across specific subgroups (for example, people with primary care-sensitive conditions) and primary care dimensions. Primary care reforms, therefore, should be person centered, addressing the needs of subgroups of patients while also finding a balance between structure and service delivery.

An Alternative Paradigm for Evidence-Based Medicine: Revisiting Lawrence Weed, MD's Systems Approach

Lawrence Weed, MD, is renowned for being the father of the Problem-Oriented Medical Record (POMR), the medical care standard for collecting, managing, and contextualizing patient data in medical records. What have been consistently overlooked are his teachings on knowledge coupling, which refers to matching patient data with associated medical knowledge. Together, the POMR standard and knowledge coupling are meant to form the basis of a systems approach that enables individualized evidence-based decision making within the context of multimorbidity and patient complexity.The POMR and knowledge coupling tools operationalize a problem-oriented model that reflects a sophisticated general systems theoretical approach to knowledge. This paradigm transcends reductionist approaches to knowledge by depicting how the meaning of specific entities (eg, disease constructs) and their associated probabilities can only be understood within their respective spatiotemporal and biopsychosocial relational contexts. Rigorous POMRs therefore require knowledge inputs from a network of interconnections among specific entities, which Dr Weed enabled through development of the Knowledge Net standard. The Knowledge Net's relational structure determines the applicability of knowledge within specific patient contexts. To enable the linkage of unique combinations of data in individual patient POMRs with existing medical knowledge structured in Knowledge Nets, Dr Weed developed the Knowledge Coupling standard.Dr Weed's standards for record keeping and knowledge coupling form the basis of a combinatorial approach to evidence-based medicine that fulfills Stange's call for a science of connectedness. Ensuing individualized processes of care become the dynamo powering a learning health care system that enables a co-construction of health premised on empowerment and intelligent human decision making, rather than promoting the artificial intelligence of tools. If the value of Engel's biopsychosocial model indeed relates to "guiding the parsimonious application of medical knowledge to the needs of each patient," Dr Weed's approach warrants serious consideration.

The impact of comorbidities on productivity loss in asthma patients

Background

Health-related productivity loss is an important, yet overlooked, component of the economic burden of disease in asthma patients of a working age. We aimed at evaluating the effect of comorbidities on productivity loss among adult asthma patients.

Methods

In a random sample of employed adults with asthma, we measured comorbidities using a validated self-administered comorbidity questionnaire (SCQ), as well as productivity loss, including absenteeism and presenteeism, using validated instruments. Productivity loss was measured in 2010 Canadian dollars ($). We used a two-part regression model to estimate the adjusted difference of productivity loss across levels of comorbidity, controlling for potential confounding variables.

Results

284 adults with the mean age of 47.8 (SD 11.8) were included (68 % women). The mean SCQ score was 2.47 (SD 2.97, range 0–15) and the average productivity loss was $317.5 per week (SD $858.8). One-unit increase in the SCQ score was associated with 14 % (95 % CI 1.02–1.28) increase in the odds of reporting productivity loss, and 9.0 % (95 % CI 1.01–1.18) increase in productivity loss among those reported any loss of productivity. A person with a SCQ score of 15 had almost $1000 per week more productivity loss than a patient with a SCQ of zero.

Conclusions

Our study deepens the evidence-base on the burden of asthma, by demonstrating that comorbidities substantially decrease productivity in working asthma patients. Asthma management strategies must be cognizant of the role of comorbidities to properly incorporate the effect of comorbidity and productivity loss in estimating the benefit of disease management strategies.

Value-based integrated (renal) care: setting a development agenda for research and implementation strategies

BACKGROUND

Integrated care services are considered a vital strategy for improving the Triple Aim values for people with chronic kidney disease. However, a solid scholarly explanation of how to develop, implement and evaluate such value-based integrated renal care services is limited. The aim of this study was to develop a framework to identify the strategies and outcomes for the implementation of value-based integrated renal care.

METHODS

First, the theoretical foundations of the Rainbow Model of Integrated Care and the Triple Aim were united into one overarching framework through an iterative process of key-informant consultations. Second, a rapid review approach was conducted to identify the published research on integrated renal care, and the Cochrane Library, Medline, Scopus, and Business Source Premier databases were searched for pertinent articles published between 2000 and 2015. Based on the framework, a coding schema was developed to synthesis the included articles.

RESULTS

The overarching framework distinguishes the integrated care domains: 1) type of integration, 2) enablers of integration and the interrelated outcome domains, 3) experience of care, 4) population health and 5) costs. The literature synthesis indicated that integrated renal care implementation strategies have particularly focused on micro clinical processes and physical outcomes, while little emphasis has been placed on meso organisational as well as macro system integration processes. In addition, evidence regarding patients' perceived outcomes and economic outcomes has been weak.

CONCLUSION

These results underscore that the future challenge for researchers is to explore which integrated care implementation strategies achieve better health and improved experience of care at a lower cost within a specific context. For this purpose, this study's framework and evidence synthesis have set a developmental agenda for both integrated renal care practice and research. Accordingly, we plan further work to develop an implementation model for value-based integrated renal services.

How Often Do Individuals with Major Depression Receive Minimally Adequate Treatment? A Population-Based, Data Linkage Study

Objective:

Depression is usually treated with antidepressants, psychotherapy, or both. In this study, we examined the extent to which individuals with depression receive minimally adequate treatment with regard to the use of antidepressants and psychotherapy.

Method:

Using population-based administrative data, we identified individuals with inpatient or outpatient diagnoses of depression and tracked their use of publicly funded mental health services within a 12-month period. We used mixed-effects logistic regression to assess the influence of patient-level characteristics and physician-level variations on the receipt of minimally adequate treatment.

Results:

A total of 108 101 individuals, predominantly women (65%) and urban residents (89%), were diagnosed with depression in 2010–2011. Of these, 13% received minimally adequate counseling/psychotherapy with higher proportions observed among men, younger individuals, and urban residents. In contrast, there were more who received minimally adequate antidepressant therapy (48%), with women, older individuals, and rural residents having the highest proportions. Overall, about 53% received either type of treatment, and the pattern of use was similar to that of antidepressant therapy. Mixed-effects logistic regression results indicate that these factors remain independent predictors of the receipt of minimally adequate depression care. Significant practice variations also exist, which determine patients’ receipt of minimally adequate care, particularly with respect to counseling or psychotherapy.

Conclusions:

Only about half of those with depression receive either minimally adequate counseling/psychotherapy or minimally adequate antidepressant therapy. Disparities also persist, affecting mostly men and younger individuals. A multifactorial approach is needed to improve access to and reduce variations in receipt of minimally adequate depression care.

Heart failure and levels of other comorbidities in patients with chronic obstructive pulmonary disease in a Swedish population: a register-based study

Background

Despite the fact that heart failure and chronic obstructive pulmonary disease (COPD) often exist together and have serious clinical and economic implications, they have mostly been studied separately. Our aim was to study prevalence of coexisting heart failure and COPD in a Swedish population. A further goal was to describe levels of other comorbidity and investigate where the patients received care: primary, secondary care or both.

Methods

We conducted a register-based, cross-sectional study. The population included all people older than 19 years, living in Östergötland County in Sweden. The data were obtained from the Care Data Warehouse register from the year 2006. The diagnosis-based Adjusted Clinical Groups Case-Mix System 7.1 was used to describe the comorbidity level.

Results

The prevalence of the diagnosis of heart failure in patients with COPD was 18.8 % while it was 1.6 % in patients without COPD. Age standardized prevalence was 9.9 and 1.5 %, respectively. Standardized relative risk for the diagnosis of heart failure in patients with COPD was 6.6. The levels of other comorbidity were significantly higher in patients with coexisting heart failure and COPD compared to patients with either heart failure or COPD alone. Primary care was the only care provider for 36.2 % of patients with the diagnosis of heart failure and 20.7 % of patients with coexisting diagnoses of heart failure and COPD. Primary care participated furthermore in shared care of 21.5 % of patients with the diagnosis of heart failure and 21.7 % of patients with coexisting diagnoses of heart failure and COPD. The share of care between primary and secondary care varied depending on levels of comorbidity both in patients with coexisting heart failure and COPD and patients with heart failure alone.

Conclusion

Patients with coexisting diagnoses of heart failure and COPD are common in the Swedish population. Patients with coexisting heart failure and COPD have higher levels of other comorbidity than patients with heart failure or COPD alone. Primary care in Sweden participates to a great extent in care of patients with diagnoses of heart failure alone and coexisting heart failure and COPD.

Adult Asylum Seekers from the Middle East Including Syria in Central Europe: What Are Their Health Care Problems?

Background

Forced displacement related to persecution and violent conflict has reached a new peak in recent years. The primary aim of this study is to provide an initial overview of the acute and chronic health care problems of asylum seekers from the Middle East, with special emphasis on asylum seekers from Syria.

Methods

Our retrospective data analysis comprised adult patients presenting to our emergency department between 01.11.2011 and 30.06.2014 with the official resident status of an “asylum seeker” or “refugee” from the Middle East.

Results

In total, 880 patients were included in the study. Of these, 625 (71.0%) were male and 255 (29.0%) female. The median age was 34 (range 16–84). 222 (25.2%) of our patients were from Syria. The most common reason for presentation was surgical (381, 43.3%), followed by medical (321, 36.5%) and psychiatric (137, 15.6%). In patients with surgical presentations, trauma-related problems were most common (n = 196, 50.6%). Within the group of patients with medical presentation, acute infectious diseases were most common (n = 141, 43.9%), followed by neurological problems (n = 70, 21.8%) and gastrointestinal problems (n = 47, 14.6%). There were no differences between Syrian and non-Syrian refugees concerning surgical or medical admissions. The most common chronic disorder of unclear significance was chronic gastrointestinal problems (n = 132, 15%), followed by chronic musculoskeletal problems (n = 108, 12.3%) and chronic headaches (n = 78, 8.9%). Patients from Syria were significantly younger and more often suffered from a post-traumatic stress disorder than patients of other nationalities (p<0.0001, and p = 0.05, respectively).

Conclusion

Overall a remarkable number of our very young group of patients suffered from psychiatric disorders and unspecified somatic symptoms. Asylum seekers should be carefully evaluated when presenting to a medical facility and physicians should be aware of the high incidence of unspecified somatic symptoms in this patient population.In general, there is no major difference between asylum seekers from Syria when compared to other nationalities of asylum seekers from the Middle East.

Multimorbidity and Its Patterns according to Immigrant Origin. A Nationwide Register-Based Study in Norway

INTRODUCTION

As the flows of immigrant populations increase worldwide, their heterogeneity becomes apparent with respect to the differences in the prevalence of chronic physical and mental disease. Multimorbidity provides a new framework in understanding chronic diseases holistically as the consequence of environmental, social, and personal risks that contribute to increased vulnerability to a wide variety of illnesses. There is a lack of studies on multimorbidity among immigrants compared to native-born populations.

METHODOLOGY

This nationwide multi-register study in Norway enabled us i) to study the associations between multimorbidity and immigrant origin, accounting for other known risk factors for multimorbidity such as gender, age and socioeconomic levels using logistic regression analyses, and ii) to identify patterns of multimorbidity in Norway for immigrants and Norwegian-born by means of exploratory factor analysis technique.

RESULTS

Multimorbidity rates were lower for immigrants compared to Norwegian-born individuals, with unadjusted odds ratios (OR) and 95% confidence intervals 0.38 (0.37-0.39) for Eastern Europe, 0.58 (0.57-0.59) for Asia, Africa and Latin America, and 0.67 (0.66-0.68) for Western Europe and North America. Results remained significant after adjusting for socioeconomic factors. Similar multimorbidity disease patterns were observed among Norwegian-born and immigrants, in particular between Norwegian-born and those from Western European and North American countries. However, the complexity of patterns that emerged for the other immigrant groups was greater. Despite differences observed in the development of patterns with age, such as ischemic heart disease among immigrant women, we were unable to detect the systematic development of the multimorbidity patterns among immigrants at younger ages.

CONCLUSIONS

Our study confirms that migrants have lower multimorbidity levels compared to Norwegian-born. The greater complexity of multimorbidity patterns for some immigrant groups requires further investigation. Health care policies and practice will require a holistic approach for specific population groups in order to meet their health needs and to curb and prevent diseases.

Multimorbidity among registered immigrants in Norway: the role of reason for migration and length of stay

OBJECTIVES

International migration is rapidly increasing worldwide. However, the health status of migrants differs across groups. Information regarding health at arrival and subsequent periodic follow-up in the host country is necessary to develop equitable health care to immigrants. The objective of this study was to determine the impact of the length of stay in Norway and other sociodemographic variables on the prevalence of multimorbidity across immigrant groups (refugees, labour immigrants, family reunification immigrants and education immigrants).

METHODS

This is a register-based study merging data from the National Population Register and the Norwegian Health Economics Administration database. Sociodemographic variables and multimorbidity across the immigrant groups were compared using Persons' chi-square test and anova as appropriate. Several binary logistic regression models were conducted.

RESULTS

Multimorbidity was significantly lower among labour immigrants (OR (95% CI) 0.23 (0.21-0.26) and 0.45 (0.40-0.50) for men and women, respectively) and education immigrants (OR (95% CI) 0.40 (0.32-0.50) and 0.38 (0.33-0.43)) and higher among refugees (OR (95% CI) 1.67 (1.57-1.78) and 1.83 (1.75-1.92)), compared to family reunification immigrants. For all groups, multimorbidity doubled after a five-year stay in Norway. Effect modifications between multimorbidity and sociodemographic characteristics across the different reasons for migration were observed.

CONCLUSIONS

Multimorbidity was highest among refugees at arrival but increased rapidly among labour immigrants, especially females. Health providers need to ensure tailor-made preventive and management strategies that take into account pre-migration and post-migration experiences for immigrants in order to address their needs.

Prevalence and outcomes of multimorbidity in South Asia: a systematic review

OBJECTIVE

To systematically review the studies of prevalence, patterns and consequences of multimorbidity reported from South Asia.

DESIGN

Systematic review.

SETTING

South Asia.

DATA SOURCES

Articles were retrieved from two electronic databases (PubMed and Embase) and from the relevant references lists. Methodical data extraction according to Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines was followed. English-language studies published between 2000 and March 2015 were included.

ELIGIBILITY CRITERIA

Studies addressing prevalence, consequences and patterns of multimorbidity in South Asia. Articles documenting presence of two or more chronic conditions were included in the review. The quality and risk of bias were assessed using STROBE criteria.

DATA SELECTION

Two reviewers independently assessed studies for eligibility, extracted data and assessed study quality. Due to heterogeneity in methodologies among reported studies, only narrative synthesis of the results was carried out.

RESULTS

Of 11,132, 61 abstracts were selected and 13 were included for final data synthesis. The number of health conditions analysed per study varied from 7 to 22, with prevalence of multimorbidity from 4.5% to 83%. The leading chronic conditions were hypertension, arthritis, diabetes, cardiac problems and skin diseases. The most frequently reported outcomes were increased healthcare utilisation, lowered physical functioning and quality of life, and psychological distress.

CONCLUSIONS

Our study, a comprehensive mapping of multimorbidity research in South Asia, reveals the insufficient volume of work carried out in this domain. The published studies are inadequate to provide an indication of the magnitude of multimorbidity in these countries. Research into clinical and epidemiological aspects of multimorbidity is warranted to build up scientific evidence in this geographic region. The wide heterogeneity observed in the present review calls for greater methodological rigour while conducting these epidemiological studies.

TRIAL REGISTRATION NUMBER

CRD42013005456.

Lead Testing in a Pediatric Population: Underscreening and Problematic Repeated Tests

CONTEXT

Underscreening and problematic repeat lead testing in children.

OBJECTIVE

Identify proportion of underscreening for elevated blood-lead levels in children. For children who receive a lead test, measure the level of problematic repeat lead tests, defined as those with a high probability of not meeting recommended guidelines for lead testing in children measured using a combination of patients' age, test type and sequencing, days between tests, and encounter diagnosis coding.

DESIGN

A population-based retrospective cross-sectional design.

SETTING

All health care services organizations in the state of Minnesota that delivered health services to the defined study population.

PARTICIPANTS

The study population was a Medicaid cohort of 12 436 children aged 0 to 18 years observed over a 1-year period.

MAIN OUTCOME MEASURES

Proportion of eligible children not receiving at least 1 lead test; proportion of problematic repeat lead tests.

RESULTS

Thirty-five percent of children who should have received at least 1 lead test (n = 1714) during the study period did not. A total of 1856 children had at least 1 lead test and 190 had 2 or more. Fifty percent (50%) of the repeat tests were identified as problematic, representing 5.1% of the lead tests performed. Repeat tests performed in different health systems than the systems where the initial tests were performed had 5.3 times greater odds (adjusted odds ratio: 5.3 [95% confidence interval, 2.8-9.9]) of being problematic.

CONCLUSIONS

The current approach to delivering mandatory lead testing across the state Medicaid population does not ensure that children are appropriately tested and has potential inefficiencies in that testing when it does take place. Use of multiple health care systems is associated with increased potential inefficiencies. Future Medicaid accountable care agreements between the state Medicaid program and participating health systems should emphasize clear population accountability for test screenings to improve patients' safety. A central queryable health resource or health information exchange may enable this.

Organizational barriers associated with the implementation of national essential medicines policy: A cross-sectional study of township hospitals in China

This study identifies potential organizational barriers associated with the implementation of the Chinese National Essential Medicines Policy (NEMP) in rural primary health care institutions. We used a multistage sampling strategy to select 90 township hospitals from six provinces, two from each of eastern, middle, and western China. Data relating to eight core NEMP indicators and institutional characteristics were collected from January to September 2011, using a questionnaire. Prescription-associated indicators were calculated from 9000 outpatient prescriptions selected at random. We categorized the eight NEMP indicators using an exploratory factor analysis, and performed linear regressions to determine the association between the factor scores and institution-level characteristics. The results identified three main factors. Overall, low levels of expenditure of medicines (F1) and poor performance in rational use of medicines (F2) were evident. The availability of medicines (F3) varied significantly across both hospitals and regions. Factor scores had no significant relationship with hospital size (in terms of number of beds and health workers); however, they were associated with revenue and structure of the hospital, patient service load, and support for health workers. Regression analyses showed that public finance per health worker was negatively associated with the availability of medicines (p < 0.05), remuneration of prescribers was positively associated with higher performance in the rational use of medicines (p < 0.05), and drug sales were negatively associated with higher levels of drug expenditure (p < 0.01). In conclusion, irrational use of medicines remains a serious issue, although the financial barriers for gaining access to essential medicines may be less for prescribers and consumers. Limited public finance from local governments may reduce medicine stock lines of township hospitals and lead them to seek alternative sources of income, jeopardizing their capacity to meet the needs of local consumers.

Do Pediatric Patients Who Receive Care Across Multiple Health Systems Have Higher Levels of Repeat Testing?

Repetition by clinicians of the same tests for a given patient is common. However, not all repeat tests are necessary for optimal care and can result in unnecessary hardship. Limited evidence suggests that an electronic health record may reduce redundant laboratory testing and imaging by making previous results accessible to physicians. The purpose of this study is to establish a baseline by characterizing repeat testing in a pediatric population and to identify significant risk factors associated with repeated tests, including the impact of using multiple health systems. A population-based retrospective cross-sectional design was used to examine initial and repeat test instances, defined as a second test following an initial test of the same type for the same patient. The study population consisted of 8760 children with 1-25 test claims over a 1-year period. The study setting included all health care service organizations in Minnesota that generated these claims. In all, 17.2% of tests met the definition of repeat test instances, with several risk factors associated with per patient repeat test levels. The incidence of repeat test instances per patient was significantly higher when patients received care from more than 1 health system (adjusted incidence rate ratio 1.4; 95% confidence interval: 1.3-1.5). Repeat test levels are significant in pediatric populations and potentially actionable. Interoperable health information technology may reduce the incidence of repeat test instances in pediatric populations by making prior test results readily accessible. (Population Health Management 2016;19:102-108).

[Analysis of the influence of the process of care in primary health care on avoidable hospitalizations for heart failure]

Objetivo

Comprobar si el proceso asistencial en Atención Primaria de Salud (APS), definido por 7 criterios de correcta atención, influye en el riesgo de hospitalizaciones evitables por Ambulatory Care Sensitive Conditions (ACSH) por insuficiencia cardíaca (IC).

Diseño

Estudio de casos y controles que analizó el riesgo de hospitalización por IC. Factor de exposición: proceso asistencial de APS.

Emplazamiento

Área sanitaria de la Comunidad de Madrid (n = 466.901).

Participantes

Pacientes mayores de 14 años con el registro del diagnóstico de IC en la historia clínica electrónica de APS (n = 3.277) antes del 1 de enero de 2007. Los casos fueron pacientes que ingresaron en el hospital de referencia por IC durante 2007. Los controles no requirieron ingreso.

Mediciones principales

Riesgo de ACSH por IC relacionado con el proceso asistencial considerado tanto de forma conjunta como por cada uno de los criterios. Diferencias en complejidad clínica mediante Adjusted Clinical Group (ACG).

Resultados

Doscientos veintisiete ingresos por IC frente a un grupo control de 3.050 pacientes. El peso medio de ACG fue mayor en los casos. Los controles tuvieron mayor cumplimentación de criterios, pero ninguno cumplió los 7. Solo en 2 de los criterios se observó menor riesgo de ACSH. A medida que no se cumplimentaba progresivamente cada criterio, el riesgo de ingresar aumentó (OR = 1,33; IC 95%: 1,19-1,49).

Conclusión

La calidad del proceso asistencial en APS influyó en el riesgo de ingreso por IC.

Methods for identifying 30 chronic conditions: application to administrative data

BACKGROUND

Multimorbidity is common and associated with poor clinical outcomes and high health care costs. Administrative data are a promising tool for studying the epidemiology of multimorbidity. Our goal was to derive and apply a new scheme for using administrative data to identify the presence of chronic conditions and multimorbidity.

METHODS

We identified validated algorithms that use ICD-9 CM/ICD-10 data to ascertain the presence or absence of 40 morbidities. Algorithms with both positive predictive value and sensitivity ≥70% were graded as "high validity"; those with positive predictive value ≥70% and sensitivity <70% were graded as "moderate validity". To show proof of concept, we applied identified algorithms with high to moderate validity to inpatient and outpatient claims and utilization data from 574,409 people residing in Edmonton, Canada during the 2008/2009 fiscal year.

RESULTS

Of the 40 morbidities, we identified 30 that could be identified with high to moderate validity. Approximately one quarter of participants had identified multimorbidity (2 or more conditions), one quarter had a single identified morbidity and the remaining participants were not identified as having any of the 30 morbidities.

CONCLUSIONS

We identified a panel of 30 chronic conditions that can be identified from administrative data using validated algorithms, facilitating the study and surveillance of multimorbidity. We encourage other groups to use this scheme, to facilitate comparisons between settings and jurisdictions.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The impact of multimorbidity on short-term events in patients with community-acquired pneumonia: prospective cohort study

The impact of multimorbidity on patients with community-acquired pneumonia has not been well characterised. Thus, our aim was to explore the relationship between multimorbidity and adverse events within 90 days of discharge. Data were prospectively collected for a population-based cohort of all adults discharged from any of the seven emergency departments (ED) or six hospitals in Edmonton (Alberta, Canada) with community-acquired pneumonia. Multivariable Cox regression models were used to examine the independent association between multimorbidity (defined as two or more chronic conditions) and subsequent 90-day mortality, hospitalisation, or ED visits after treatment of pneumonia. The cohort included 5565 patients, mean age was 57 years (SD 20), 54% were male, and 59% were treated as outpatients; 1602 (29%) patients had multimorbidity. Within 90 days, 255 (5%) patients died, 1205 (22%) were hospitalised, 1280 (23%) died or were hospitalised, and 2049 (37%) were admitted to the ED. The presence of multimorbidity was independently associated with an increased risk of death or hospitalisation within 90 days (37% vs. 17% for those without multimorbidity, adjusted hazard ratio: 1.43, 95% confidence interval: 1.26 to 1.62) as well as ED visits (45% vs. 34%, adjusted hazard ratio: 1.40, 95% confidence interval: 1.26 to 1.56). Multimorbidity was present in one-third of all patients with pneumonia in our study, and it was independently associated with death, hospitalisation, or return to ED within 90 days of discharge. Our findings suggest that multimorbidity is strongly related to prognosis and should be considered when making site-of-care decisions in the ED or deciding upon readiness for discharge.

Multimorbidity in a marginalised, street-health Australian population: a retrospective cohort study

OBJECTIVES

Demographic and presentation profile of patients using an innovative mobile outreach clinic compared with mainstream practice.

DESIGN

Retrospective cohort study.

SETTING

Primary care mobile street health clinic and mainstream practice in Western Australia.

PARTICIPANTS

2587 street health and 4583 mainstream patients.

MAIN OUTCOME MEASURES

Prevalence and patterns of chronic diseases in anatomical domains across the entire age spectrum of patients and disease severity burden using Cumulative Illness Rating Scale (CIRS).

RESULTS

Multimorbidity (2+ CIRS domains) prevalence was significantly higher in the street health cohort (46.3%, 1199/2587) than age-sex-adjusted mainstream estimate (43.1%, 2000/4583), p=0.011. Multimorbidity prevalence was significantly higher in street health patients <45 years (37.7%, 615/1649) compared with age-sex-adjusted mainstream patients (33%, 977/2961), p=0.003 but significantly lower if 65+ years (62%, 114/184 vs 90.7%, 322/355, p<0.001). Controlling for age and gender, the mean CIRS Severity Index score for street health (M=1.4, SD=0.91) was significantly higher than for mainstream patients (M=1.1, SD=0.80), p<0.001. Furthermore, 44.2% (530/1199) of street health patients had at least one level 3 or 4 score across domains compared with 18.3% (420/2294) for mainstream patients, p<0.001. Street health population comprised 29.6% (766/2587) Aboriginal patients with 50.4% (386/766) having multimorbidity compared with 44.6% (813/1821) for non-Aboriginals, p=0.007. There were no comprehensive data on Indigenous status in the mainstream cohort available for comparison. Musculoskeletal, respiratory and psychiatric domains were most commonly affected with multimorbidity significantly associated with male gender, increasing age and Indigenous status.

CONCLUSIONS

Age-sex-adjusted multimorbidity prevalence and disease severity is higher in the street health cohort. Earlier onset (23-34 years) multimorbidity is found in the street health cohort but prevalence is lower in 65+ years than in mainstream patients. Multimorbidity prevalence is higher for Aboriginal patients of all ages.