Critiques of the risk concept--valid or not?

The effect of disease onset chronology on mortality among patients with multimorbidity: A Danish nationwide register study

Background

Multimorbidity is associated with increased mortality. Certain combinations of diseases are known to be more lethal than others, but the limited knowledge of how the chronology in which diseases develop impacts mortality may impair the development of effective clinical interventions for patients with multimorbidity.

Objective

To explore if in multimorbidity the chronology of disease onset is associated with mortality. Design: A prospective nationwide cohort study, including 3,986,209 people aged ≥18 years on 1 January 2000, was performed. We included ten diagnosis groups: lung, musculoskeletal, endocrine, mental, cancer, neurological, gastrointestinal, cardiovascular, kidney, and sensory organs. We defined multimorbidity as the presence of at least two diagnoses from two diagnosis groups (out of ten). To determine mortality, logistic regression models were used to calculate odds ratios (OR) and ratio of ORs (RORs).

Results

For most combinations of multimorbidity, the chronology of disease onset does not change mortality. However, when multimorbidity included mental health diagnoses, mortality was in general higher if the mental health diagnosis appeared first. If multimorbidity included heart and sensory diagnoses, mortality was higher if these developed second. For the majority of multimorbidity combinations, there was excess mortality if multimorbidity was diagnosed simultaneously, rather than consecutively, for example, heart and kidney (3.58 ROR; CI 2.39–5.36), or mental health and musculoskeletal diagnoses (2.38 ROR; CI 1.70–3.32).

Conclusions

Overall, in multimorbidity, the chronology in which diseases develop is not associated with mortality, with few exceptions. For almost all combinations of multimorbidity, diagnoses act synergistically in relation to mortality if diagnosed simultaneously.

Propiedades psicométricas de una escala de resiliencia en cuidadores familiares de adultos mayores

El cuidado de un adulto mayor se ha estudiado no solo como una circunstancia generadora de estrés y deterioro del bienestar para el cuidador, sino también, desde la perspectiva de la psicología positiva, como la disposición de los cuidadores para reaccionar de manera resiliente ante las dificultades experimentadas. El objetivo del presente estudio fue realizar la validación de constructo del Inventario de Resiliencia (IRES) mediante algunos procedimientos exploratorios y confirmatorios. Para ello, se colectaron datos de dos muestras independientes de cuidadores familiares de adultos mayores en la ciudad de Hermosillo, México: la primera con 125 cuidadores de 19 a 73 años (Medad = 47.8, DE = 12) para los análisis factoriales exploratorios; y la segunda con 160 cuidadores de 19 a 82 años (Medad = 48.7, DE = 13) para los análisis factoriales confirmatorios. Los análisis revelaron dos dimensiones claras y robustas estadísticamente en el IRES con 12 ítems: la resiliencia instrumental y la resiliencia emocional. En conclusión, la presente investigación muestra que el IRES es un instrumento válido para la medición de la resiliencia en una población mexicana de cuidadores familiares de adultos mayores.

Categorization and association analysis of risk factors for adverse drug events

PURPOSE

Adverse drug events (ADE) are among the leading causes of morbidity and hospitalization. This review analyzes risk factors for ADE, particularly their categorizations and association patterns, the prevalence, severity, and preventability of ADE, and method characteristics of reviewed studies.

METHODS

Literature search was conducted via PubMed, Science Direct, CINAHL, and MEDLINE. A review was conducted of research articles that reported original data about specific risk factors for ADE since 2000. Data analyses were performed using Excel and R.

RESULTS

We summarized 211 risk factors for ADE, and grouped them into five main categories: patient-, disease-, medication-, health service-, and genetics-related. Among them, medication- and disease-related risk factors were most frequently studied. We further classified risk factors within each main category into subtypes. Among them, polypharmacy, age, gender, central nervous system agents, comorbidity, service utilization, inappropriate use/change use of drugs, cardiovascular agents, and anti-infectives were most studied subtypes. An association analysis of risk factors uncovered many interesting patterns. The median prevalence, preventability, and severity rate of reported ADE was 19.5% (0.29%~86.2%), 36.2% (2.63%~91%), and 16% (0.01%~47.4%), respectively.

CONCLUSIONS

This review introduced new categories and subtypes of risk factors for ADE. The broad and in-depth coverage of risk factors and their association patterns elucidate the complexity of risk factor analysis. Managing risk factors for ADE is crucial for improving patient safety, particularly for the elderly, comorbid, and polypharmacy patients. Some under-explored risk factors such as genetics, mental health and wellness, education, lifestyle, and physical environment invite future research.

The role of diseases, risk factors and symptoms in the definition of multimorbidity - a systematic review

Objective is to explore how multimorbidity is defined in the scientific literature, with a focus on the roles of diseases, risk factors, and symptoms in the definitions.

DESIGN

Systematic review.

METHODS

MEDLINE (PubMed), Embase, and The Cochrane Library were searched for relevant publications up until October 2013. One author extracted the information. Ambiguities were resolved, and consensus reached with one co-author. Outcome measures were: cut-off point for the number of conditions included in the definitions of multimorbidity; setting; data sources; number, kind, duration, and severity of diagnoses, risk factors, and symptoms. We reviewed 163 articles. In 61 articles (37%), the cut-off point for multimorbidity was two or more conditions (diseases, risk factors, or symptoms). The most frequently used setting was the general population (68 articles, 42%), and primary care (41 articles, 25%). Sources of data were primarily self-reports (56 articles, 42%). Out of the 163 articles selected, 115 had individually constructed multimorbidity definitions, and in these articles diseases occurred in all definitions, with diabetes as the most frequent. Risk factors occurred in 98 (85%) and symptoms in 71 (62%) of the definitions. The severity of conditions was used in 26 (23%) of the definitions, but in different ways. The definition of multimorbidity is heterogeneous and risk factors are more often included than symptoms. The severity of conditions is seldom included. Since the number of people living with multimorbidity is increasing there is a need to develop a concept of multimorbidity that is more useful in daily clinical work. Key points The increasing number of multimorbidity patients challenges the healthcare system. The concept of multimorbidity needs further discussion in order to be implemented in daily clinical practice. Many definitions of multimorbidity exist and most often a cut-off point of two or more is applied to a range of 4-147 different conditions. Diseases are included in all definitions of multimorbidity. Risk factors are often included in existing definitions, whereas symptoms and the severity of the conditions are less frequently included.

Communicating risk using absolute risk reduction or prolongation of life formats: cluster-randomised trial in general practice

BACKGROUND

It is important that patients are well-informed about risks and benefits of therapies to help them decide whether to accept medical therapy. Different numerical formats can be used in risk communication but It remains unclear how the different formats affect decisions made by real-life patients.

AIM

To compare the impact of using Prolongation Of Life (POL) and Absolute Risk Reduction (ARR) information formats to express effectiveness of cholesterol-lowering therapy on patients' redemptions of statin prescriptions, and on patients' confidence in their decision and satisfaction with the risk communication.

DESIGN AND SETTING

Cluster-randomised clinical trial in general practices. Thirty-four Danish GPs from 23 practices participated in a primary care-based clinical trial concerning use of quantitative effectiveness formats for risk communication in health prevention consultations.

METHOD

GPs were cluster-randomised (treating practices as clusters) to inform patients about cardiovascular mortality risk and the effectiveness of statin treatment using either POL or ARR formats. Patients' redemptions of statin prescriptions were obtained from a regional prescription database. The COMRADE questionnaire was used to measure patients' confidence in their decision and satisfaction with the risk communication.

RESULTS

Of the 240 patients included for analyses, 112 were allocated to POL information and 128 to ARR. Patients redeeming a statin prescription totalled six (5.4%) when informed using POL, and 32 (25.0%) when using ARR. The level of confidence in decision and satisfaction with risk communication did not differ between the risk formats.

CONCLUSION

Patients redeemed statin prescriptions less often when their GP communicated treatment effectiveness using POL compared with ARR.

Risk: a multidisciplinary concept analysis

PURPOSE

To analyze the concept of risk utilizing Walker and Avant's method of analysis to determine a conceptual definition applicable within nursing and nursing research.

CONCLUSION

The mental constructs and consequences of risk have a proactive connotation compared with the negative behaviors often identified as illustrations of risk.

PRACTICE APPLICATION

A new conceptual definition of risk provides insight into an understanding of risk regardless of discipline. Its application to the metaparadigm of nursing should be the impetus for action and education. Formalizing the mental constructs of the concept of risk in a clear manner facilitates the inclusion of its latent constructs in nursing research.

Risk in Maternity Care: A Concept Analysis

AIM: To analyze the concept of risk in maternity care.

DATA SOURCES: MEDLINE (1966–2010), CINAHL (1980–2010), EMBASE (1980–2010), PsycINFO (1980–2010), and Social Science Citation Index were searched. Key text books were sourced. Media literature was reviewed by perusal of newspaper articles, health supplements, and popular Internet health care websites.

REVIEW METHODS: The principle-based method of concept analysis was used to guide the analysis of risk in maternity care.

RESULTS: The epistemological principle identified the ambiguous nature of the risk concept, with risk having diverse meanings for different individuals. The pragmatic principle demonstrated that the current systematic approach to risk assessment often fails to identify those who succumb to risk issues. The linguistic principle portrays the ambiguity of risk perception with “risk” considered according to past experiences, knowledge, and individual attitudes. The logical principle identified a strong link between safety and uncertainty revealing that the risk concept lacks integrity and may not “hold its own.”

CONCLUSION: The concept of risk in maternity care is concerned with risk assessment, risk perception, and notions of safety and uncertainty. Risk in maternity care is diverse and dynamic. What constitutes as a risk today may not necessarily be viewed in the same light tomorrow.

Managing scientific uncertainty in medical decision making: the case of the advisory committee on immunization practices

This article explores the question of how scientific uncertainty can be managed in medical decision making using the Advisory Committee on Immunization Practices as a case study. It concludes that where a high degree of technical consensus exists about the evidence and data, decision makers act according to a clear decision rule. If a high degree of technical consensus does not exist and uncertainty abounds, the decision will be based on a variety of criteria, including readily available resources, decision-process constraints, and the available knowledge base, among other things. Decision makers employ a variety of heuristic devices and techniques, thereby employing a pragmatic approach to uncertainty in medical decision making. The article concludes with recommendations for managing scientific uncertainty in medical decision making.

Positive predictive values of ≥5% in primary care for cancer: systematic review

BACKGROUND

The positive predictive value (PPV) for cancer of symptoms, signs, and non-diagnostic test results of patients routinely consulting a GP (unselected primary care populations) can help to determine when malignancy should be excluded. Comparisons with other illness indicate that a value of 5% or more may be regarded as highly predictive.

AIM

To identify symptoms, signs, and non-diagnostic test results in unselected primary care populations that are highly predictive of cancer.

DESIGN OF STUDY

Systematic review.

SETTING

Primary care.

METHOD

Fourteen bibliographic databases were searched, using terms for primary care, cancer, and predictive values. Reference lists of relevant papers were hand-searched. Data were extracted and the quality of each paper was assessed using predefined criteria, and checked by a second reviewer.

RESULTS

Twenty-five studies were identified. PPVs of 5% or more in specific age and sex groups were reported for: rectal bleeding, change in bowel habit, and iron deficiency anaemia and colorectal cancer; haematuria and urological cancer; malignant rectal examination and prostate cancer; haemoptysis and lung cancer; dysphagia and oesophageal cancer; breast lump and breast cancer; and postmenopausal bleeding and gynaecological cancer.

CONCLUSION

Robust evidence was found for eight symptoms, signs, and non-diagnostic test results as strongly indicative of cancer for specific age and sex groups in unselected primary care populations. These have the potential to improve the early diagnosis of some cancers in primary care by the use of computer warning flags, improved guidelines, audit, and appraisal.