Costs associated with multimorbidity among VA patients

Changes in patterns of multimorbidity and associated with medical costs among Chinese middle-aged and older adults from 2013 to 2023: an analysis of repeated cross-sectional surveys in Xiangyang, China

Background

Multimorbidity has become a major public health problem among Chinese middle-aged and older adults, and the most costly to the health care system. However, most previous population-based studies of multimorbidity have focused on a limited number of chronic diseases, and diagnosis was based on participants' self-report, which may oversimplify the problem. At the same time, there were few reports on the relationship between multimorbidity patterns and health care costs. This study analyzed the multimorbidity patterns and changes among middle-aged and older people in China over the past decade, and their association with medical costs, based on representative hospital electronic medical record data.

Methods

Two cross-sectional surveys based on representative hospital data were used to obtain adults aged 45 years and older in Xiangyang in 2013 (n = 20,218) and 2023 (n = 63,517). Latent Class Analysis was used to analyze changes in the patterns of multimorbidity, gray correlation analysis and ordered logistics model were used to assess the association of multimorbidity patterns with medical expenses. The diagnosis and classification of chronic diseases were based on the International Classification of Diseases, Tenth Revision codes (ICD-10).

Results

The detection rate of chronic disease multimorbidity has increased (70.74 vs. 76.63%, p < 0.001), and multimorbidity patterns have increased from 6 to 9 (2013: Malignant tumors pattern, non-specific multimorbidity pattern, ischemic heart disease + hypertension pattern, cerebral infarction + hypertension pattern, kidney disease + hypertension pattern, lens disease + hypertension pattern; new in 2023: Nutritional metabolism disorders + hypertension pattern, chronic lower respiratory diseases + malignant tumors pattern, and gastrointestinal diseases pattern) in China. The medical cost of all multimorbidity patients have been reduced between 2013 and 2023 (RMB: 8216.74 vs. 7247.96, IQR: 5802.28-15,737 vs. 5014.63-15434.06). The top three specific multimorbidity patterns in both surveys were malignancy tumor pattern, ischemic heart disease + hypertension pattern, and cerebral infarction + hypertension pattern. Hypertension and type 2 diabetes are important components of multimorbidity patterns. Compared with patients with a single disease, only lens disorders + hypertension pattern were at risk of higher medical costs in 2013 (aOR:1.23, 95% CI: 1.03, 1.47), whereas all multimorbidity patterns were significantly associated with increased medical costs in 2023, except for lens disorders + hypertension (aOR:0.35, 95% CI: 0.32, 0.39). Moreover, the odds of higher medical costs were not consistent across multimorbidity patterns. Among them, ischemic heart disease + hypertension pattern [adjusted odds ratio (aOR):4.66, 95%CI: 4.31, 5.05] and cerebral infarction + hypertension pattern (aOR: 3.63, 95% CI: 3.35, 3.92) were the two patterns with the highest risk. Meanwhile, men (aOR:1.12, 95CI:1.09, 1.16), no spouse (aOR:1.09, 95CI: 1.03, 1.16) had a positive effect on medical costs, while patients with total self-pay (aOR: 0.45, 95CI: 0.29, 0.70), no surgery (aOR: 0.05, 95CI: 0.05, 0.05), rural residence (aOR: 0.92, 95CI: 0.89, 0.95), hospitalization days 1-5 (aOR: 0.04, 95CI: 0.04, 0.04), and hospitalization days 6-9 (aOR: 0.15, 95CI: 0.15, 0.16) had a negative impact on medical costs.

Conclusion

Multimorbidity patterns among middle-aged and older adults in China have diversified over the past decade and are associated with rising health care costs in China. Smart, decisive and comprehensive policy and care interventions are needed to effectively manage NCDS and their risk factors and to reduce the economic burden of multimorbidity on patients and the country.

Medication regimen complexity and its impact on medication adherence in patients with multimorbidity at a comprehensive specialized hospital in Ethiopia

Background

Medication regimen complexity (MRC) is suspected to hinder medication adherence in patients with multiple illnesses. Despite this, the specific impact on Ethiopian patients with multimorbidity is unclear. This study assessed MRC and its impact on medication adherence in patients with multimorbidity.

Methods

A hospital-based cross-sectional study was conducted on patients with multimorbidity who had been followed at the University of Gondar Comprehensive and Specialized Hospital (UoGCSH), Ethiopia, from May to July 2021. Medication complexity was measured using the validated Medication Regimen Complexity Index (MRCI) tool, and the Adherence in Chronic Diseases Scale (ACDS) was used to measure medication adherence. Pearson's chi-square test was used to examine associations between MRCI levels and medication adherence. Ordinal logistic regression analysis was used to determine the impact of MRC and other associated variables on medication adherence. Statistical significance was determined using the adjusted odds ratio (AOR) at p-value <0.05 and its 95% confidence range.

Results

Out of 422 eligible patients, 416 (98.6%) were included in the study. The majority of participants (57.2%) were classified as having a high MRCI score with a mean (±SD) score of 9.7 (±3.4). Nearly half of the patients (49.3%) had low medication adherence. Patients with medium (AOR = 0.43, 95% CI: 0.04, 0.72) and higher (AOR = 0.31, 95% CI: 0.07, 0.79) MRCI levels had lower odds of medication adherence. In addition, monthly income (AOR = 4.59, 95% CI: 2.14, 9.83), follow-up durations (AOR = 2.31, 95% CI: 1.09, 4.86), number of medications (AOR = 0.63, 95% CI: 0.41, 0.97), and Charlson comorbidity index (CCI) (AOR = 0.36, 95% CI: 0.16, 0.83) were significantly associated with medication adherence.

Conclusion

Medication regimen complexity in patients with multimorbidity was found to be high and negatively impacted the levels of medication adherence. Healthcare providers and other stakeholders should seek interventions aimed at simplifying drug regimen complexity and improving adherence.

Multimorbidity healthcare expenditure in Belgium: a 4-year analysis (COMORB study)

BACKGROUND

The complex management of health needs in multimorbid patients, alongside limited cost data, presents challenges in developing cost-effective patient-care pathways. We estimated the costs of managing 171 dyads and 969 triads in Belgium, taking into account the influence of morbidity interactions on costs.

METHODS

We followed a retrospective longitudinal study design, using the linked Belgian Health Interview Survey 2018 and the administrative claim database 2017-2020 hosted by the Intermutualistic Agency. We included people aged 15 and older, who had complete profiles (N = 9753). Applying a system costing perspective, the average annual direct cost per person per dyad/triad was presented in 2022 Euro and comprised mainly direct medical costs. We developed mixed models to analyse the impact of single chronic conditions, dyads and triads on healthcare costs, considering two-/three-way interactions within dyads/triads, key cost determinants and clustering at the household level.

RESULTS

People with multimorbidity constituted nearly half of the study population and their total healthcare cost constituted around three quarters of the healthcare cost of the study population. The most common dyad, arthropathies + dorsopathies, with a 14% prevalence rate, accounted for 11% of the total national health expenditure. The most frequent triad, arthropathies + dorsopathies + hypertension, with a 5% prevalence rate, contributed 5%. The average annual direct costs per person with dyad and triad were €3515 (95% CI 3093-3937) and €4592 (95% CI 3920-5264), respectively. Dyads and triads associated with cancer, diabetes, chronic fatigue, and genitourinary problems incurred the highest costs. In most cases, the cost associated with multimorbidity was lower or not substantially different from the combined cost of the same conditions observed in separate patients.

CONCLUSION

Prevalent morbidity combinations, rather than high-cost ones, made a greater contribution to total national health expenditure. Our study contributes to the sparse evidence on this topic globally and in Europe, with the aim of improving cost-effective care for patients with diverse needs.

Defining and Improving Outcomes Measurement for Virtual Care: Report from the VHA State-of-the-Art Conference on Virtual Care

Virtual care, including synchronous and asynchronous telehealth, remote patient monitoring, and the collection and interpretation of patient-generated health data (PGHD), has the potential to transform healthcare delivery and increase access to care. The Veterans Health Administration (VHA) Office of Health Services Research and Development (HSR&D) convened a State-of-the-Art (SOTA) Conference on Virtual Care to identify future virtual care research priorities. Participants were divided into three workgroups focused on virtual care access, engagement, and outcomes. In this article, we report the findings of the Outcomes Workgroup. The group identified virtual care outcome areas with sufficient evidence, areas in need of additional research, and areas that are particularly well-suited to be studied within VHA. Following a rigorous process of literature review and consensus, the group focused on four questions: (1) What outcomes of virtual care should we be measuring and how should we measure them?; (2) how do we choose the "right" care modality for the "right" patient?; (3) what are potential consequences of virtual care on patient safety?; and (4) how can PGHD be used to benefit provider decision-making and patient self-management?. The current article outlines key conclusions that emerged following discussion of these questions, including recommendations for future research.

Frontline perspectives on adoption and non-adoption of care management tools for high-risk patients in primary care

BACKGROUND

Population health management tools (PHMTs) embedded within electronic health records (EHR) could improve management of high-risk patients and reduce costs associated with potentially avoidable emergency department visits or hospitalizations. Adoption of PHMTs across the Veterans Health Administration (VA) has been variable and previous research suggests that understaffed primary care (PC) teams might not be using the tools.

METHODS

We conducted a retrospective content analysis of open-text responses (n = 1804) from the VA's 2018 national primary care personnel survey to, 1) identify system-level and individual-level factors associated with why clinicians are not using the tools, and 2) to document clinicians' recommendations to improve tool adoption.

RESULTS

We found three themes pertaining to low adoption and/or tool use: 1) IT burden and administrative tasks (e.g., manually mailing letters to patients), 2) staffing shortages (e.g., nurses covering multiple teams), and 3) no training or difficulty using the tools (e.g., not knowing how to access the tools or use the data). Frontline clinician recommendations included automating some tasks, reconfiguring team roles to shift administrative work away from providers and nurses, consolidating PHMTs into a centralized, easily accessible repository, and providing training.

CONCLUSIONS

Healthcare system-level factors (staffing) and individual-level factors (lack of training) can limit adoption of PHMTs that could be useful for reducing costs and improving patient outcomes. Future research, including qualitative interviews with clinicians who use/don't use the tools, could help develop interventions to address barriers to adoption.

IMPLICATIONS

Shifting more administrative tasks to clerical staff would free up clinician time for population health management but may not be possible for understaffed PC teams. Additionally, healthcare systems may be able to increase PHMT use by making them more easily accessible through the electronic health record and providing training in their use.

Older Veterans' Experiences of a Multicomponent Telehealth Program: Qualitative Program Evaluation Study

BACKGROUND

There are 8.8 million American veterans aged >65 years. Older veterans often have multiple health conditions that increase their risk of social isolation and loneliness, disability, adverse health events (eg, hospitalization and death), mental illness, and heavy health care use. This population also exhibits low levels of physical function and daily physical activity, which are factors that can negatively influence health. Importantly, these are modifiable risk factors that are amenable to physical therapy intervention. We used a working model based on the dynamic biopsychosocial framework and social cognitive theory to conceptualize the multifactorial needs of older veterans with multiple health conditions and develop a novel, 4-component telehealth program to address their complex needs.

OBJECTIVE

This study aims to describe veterans' experiences of a multicomponent telehealth program and identify opportunities for quality and process improvement. We conducted qualitative interviews with telehealth program participants to collect their feedback on this novel program; explore their experience of program components; and document perceived outcomes and the impact on their daily life, relationships, and quality of life.

METHODS

As part of a multimethod program evaluation, semistructured interviews were conducted with key informants who completed ≥8 weeks of the 12-week multicomponent telehealth program for veterans aged ≥50 years with at least 3 medical comorbidities. Interviews were audio recorded and transcribed. Data were analyzed by a team of 2 coders using a directed content analysis approach and Dedoose software was used to assist with data analysis.

RESULTS

Of the 21 individuals enrolled in the program, 15 (71%) met the inclusion criteria for interviews. All 15 individuals completed 1-hour interviews. A total of 6 main conceptual domains were identified: technology, social networks, therapeutic relationship, patient attributes, access, and feasibility. Themes associated with each domain detail participant experiences of the telehealth program. Key informants also provided feedback related to different components of the program, leading to adaptations for the biobehavioral intervention, group sessions (transition from individual to group sessions and group session dynamics), and technology supports.

CONCLUSIONS

Findings from this program evaluation identified quality and process improvements, which were made before rigorously testing the intervention in a larger population through a randomized controlled trial. The findings may inform adaptations of similar programs in different contexts. Further research is needed to develop a deeper understanding of how program components influence social health and longer-term behavior change.

Sociodemographic and lifestyle determinants of multimorbidity among community-dwelling older adults: findings from 346,760 SHARE participants

BACKGROUND

This study aimed to investigate the prevalence of multimorbidity and its associated factors among the older population in China to propose policy recommendations for the management of chronic diseases in older adults.

METHODS

This study was conducted based on the 2021 Shenzhen Healthy Ageing Research (SHARE), and involved analysis of 346,760 participants aged 65 or older. Multimorbidity is defined as the presence of two or more clinically diagnosed or non self-reported chronic diseases among the eight chronic diseases surveyed in an individual. The Logistic analysis was adopted to explore the potential associated factors of multimorbidity.

RESULTS

The prevalences of obesity, hypertension, diabetes, anemia, chronic kidney disease, hyperuricemia, dyslipidemia and fatty liver disease were 10.41%, 62.09%, 24.21%, 12.78%, 6.14%, 20.52%, 44.32%, and 33.25%, respectively. The prevalence of multimorbidity was 63.46%. The mean count of chronic diseases per participant was 2.14. Logistic regression indicated that gender, age, marriage status, lifestyle (smoking status, drinking status, and physical activity), and socioeconomic status (household registration, education level, payment method of medical expenses) were the common predictors of multimorbidity for older adults, among which, being women, married, or engaged in physical activity was found to be a relative determinant as a protective factor for multimorbidity after the other covariates were controlled.

CONCLUSION

Multimorbidity is prevalent among older adults in Chinese. Guideline development, clinical management,and public intervention should target a group of diseases instead of a single condition.

"A reinstilled hope that they can change": Facilitator perspectives on a self-care and health promotion peer group program for veterans

Introduction

This study assessed the relevance, value, and effectiveness of "Taking Charge of My Life and Health" (TCMLH), a patient wellbeing peer group program for U.S. veterans focused on empowering them to identify what really matters in their lives and to work toward health goals that align with their mission, aspirations, or purpose in life. The potential of TCMLH to empower veterans to engage in self-care behaviors, make health behavior changes, and participate in health care decision making is important, as veterans are more likely than the general population to suffer from multiple chronic conditions that require ongoing self-management.

Methods

We conducted individual semi-structured interviews with 19 TCMLH facilitators serving in eight U.S. Veteran's Health Administration medical centers. Data were analyzed using an inductive approach to identify salient themes in facilitators' experiences.

Results

Facilitators reported that TCMLH participants demonstrated positive attitude changes (e.g., greater confidence and hope) and behavior changes (e.g., making healthcare appointments and implementing self-care practices) by program completion. Further, findings show that mindful awareness practices, the peer group setting, Whole Health assessment tools, and goal setting tools were perceived as the most impactful program elements leading to positive health behavior change.

Conclusion

Overall, findings suggest that this non-clinical peer group program can enhance patient wellbeing, and that there are certain program elements of TCMLH that are driving key attitudinal and behavioral changes.

Systematic Literature Review of the Prevalence, Pattern, and Determinant of Multimorbidity Among Older Adults in Nigeria

Introduction

Multimorbidity is a rising health issue globally and it is likely to become challenging in developing countries like Nigeria as they experience economic, demographic, and epidemiological transition. Yet, evidence of prevalence and patterns of multimorbidity, and their determinants, are scarce. This study aims to systematically review studies of the prevalence, patterns, and determinants of multimorbidity in Nigeria.

Methods

Studies were identified by searching 5 electronic databases (PubMed, Web of Science, CINAHL, PsycINFO, Africa Index Medicus/Global Index Medicus). Multimorbidity as well as other versions of it was used to search. The prevalence and determinants were also searched. According to preestablished inclusion criteria, and using different search strategies, 6 articles were included. The quality and risk of bias were assessed using Joanna Briggs Institute appraisal tool for prevalence studies. Two researchers assessed the eligibility of studies for inclusion. The protocol was registered on PROSPERO Ref no. CRD42021273222. The overall prevalence, pattern, and determinants were analyzed.

Results

We identified 6 eligible publications describing studies that included a total of 3332 (men 47.5%, women 52.5%) patients from 4 states plus the federal capital territory Abuja. The multimorbidity prevalence ranges from 27% to 74% among elderly Nigerians. Cardiovascular together with metabolic and/or musculoskeletal conditions were the frequent patterns of multimorbidity. A positive association was observed between age and multimorbidity in most studies. Other factors associated with multimorbidity were female gender, low education status, poor monthly income/unemployment, hospitalization, medical visits, and emergency services.

Conclusion

There has been a growing need for more applied health services research to understand better and manage multimorbidity in developed countries. The scarcity of studies in our review reveals that multimorbidity is not a priority area of research in Nigeria, and this will continue to hinder policy development in that area.

The unique association of posttraumatic stress disorder with hypertension among veterans: A replication of Kibler et al. (2009) using Bayesian estimation and data from the United States-Veteran Microbiome Project

OBJECTIVE

Kibler et al. (2009) reported that hypertension was related to PTSD independent of depression. These two conditions have significant diagnostic overlap. The present study sought to conceptually replicate this work with a veteran sample, using Bayesian estimation to directly update past results, as well as examine symptom severity scores in relation to hypertension.

METHOD

This was a secondary analysis of data obtained from the United States-Veteran Microbiome Project. Lifetime diagnoses of PTSD and major depressive disorder (MDD) were obtained from a structured clinical interview and hypertension diagnoses were extracted from electronic medical records. PTSD and depressive symptom severity were obtained from self-report measures. Logistic regressions with Bayesian estimation were used to estimate the associations between hypertension and (a) psychiatric diagnostic history and (b) symptom severity scores.

RESULTS

Compared with veterans without lifetime diagnoses of either disorder, the PTSD-only group was estimated to have a 29% increase in hypertension risk, and the PTSD + MDD group was estimated to have a 66% increase in hypertension risk. Additionally, higher levels of PTSD symptom severity were associated with a higher risk of hypertension.

CONCLUSION

PTSD diagnosis and symptom severity are uniquely associated with hypertension, independent of MDD or depressive symptom severity. These results support previous findings that PTSD might be a modifiable risk factor for the prevention and treatment of hypertension. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Combinational Regularity Analysis (CORA) - a new method for uncovering complex causation in medical and health research

BACKGROUND

Modern configurational comparative methods (CCMs) of causal inference, such as Qualitative Comparative Analysis (QCA) and Coincidence Analysis (CNA), have started to make inroads into medical and health research over the last decade. At the same time, these methods remain unable to process data on multi-morbidity, a situation in which at least two chronic conditions are simultaneously present. Such data require the capability to analyze complex effects. Against a background of fast-growing numbers of patients with multi-morbid diagnoses, we present a new member of the family of CCMs with which multiple conditions and their complex conjunctions can be analyzed: Combinational Regularity Analysis (CORA).

METHODS

The technical heart of CORA consists of algorithms that have originally been developed in electrical engineering for the analysis of multi-output switching circuits. We have adapted these algorithms for purposes of configurational data analysis. To demonstrate CORA, we provide several example applications, both with simulated and empirical data, by means of the eponymous software package CORA. Also included in CORA is the possibility to mine configurational data and to visualize results via logic diagrams.

RESULTS

For simple single-condition analyses, CORA's solution is identical with that of QCA or CNA. However, analyses of multiple conditions with CORA differ in important respects from analyses with QCA or CNA. Most importantly, CORA is presently the only configurational method able to simultaneously explain individual conditions as well as complex conjunctions of conditions.

CONCLUSIONS

Through CORA, problems of multi-morbidity in particular, and configurational analyses of complex effects in general, come into the analytical reach of CCMs. Future research aims to further broaden and enhance CORA's capabilities for refining such analyses.

Patterns and Determinants of Multimorbidity in Older Adults: Study in Health-Ecological Perspective

(1) Background: Multimorbidity has become one of the key issues in the public health sector. This study aims to explore the patterns and health-ecological factors of multimorbidity in China to propose policy recommendations for the management of chronic diseases in the elderly. (2) Methods: A multi-stage random sampling method was used to conduct a questionnaire survey on 3637 older adults aged 60 and older in Shanxi, China. Association rule mining analysis (ARM) and network analysis were applied to analyze the patterns of multimorbidity. The health-ecological model was adopted to explore the potential associated factors of multimorbidity in a multidimensional perspective. A hierarchical multiple logistic model was employed to investigate the association strengths reflected by adjusted odds ratios and 95% confidence. (3) Results: Multimorbidity occurred in 20.95% of the respondents. The graph of network analysis showed that there were 6 combinations of chronic diseases with strong association strengths and 14 with moderate association strengths. The results of the ARM were similar to the network analysis; six dyadic chronic disease combinations and six triadic ones were obtained. Hierarchical multiple logistic regression indicated that innate personal traits (age, history of genetics, and body mass index), behavioral lifestyle (physical activity levels and medication adherence), interpersonal network (marital status), and socioeconomic status (educational level) were the common predictors of multimorbidity for older adults, among which, having no family history was found to be a relative determinant as a protective factor for multimorbidity after controlling the other covariates. (4) Conclusions: multimorbidity was prevalent in older adults and most disease combinations are associated with hypertension, followed by diabetes. This shows that diabetes and hypertension have a high prevalence among older adults and have a wide range of associations with other chronic diseases. Exploring the patterns and associated factors of multimorbidity will help the country prevent complications and avoid the unnecessary use of the health service, adopting an integrated approach to managing multimorbidity rather than an individual disease-specific approach and implementing different strategies according to the location of residence.

Understanding the processes behind the decisions – GPs and complex multimorbidity decision making

Complex multimorbidity, defined either as three or more chronic conditions affecting three or more different body systems or by the patients General Practitioner (GPs), is associated with various adverse outcomes. Understanding how GPs reach decisions for this complex group of patients is currently under-researched, with potential implications for health systems and service delivery. Schuttner and colleagues, through a qualitative approach, reported that internal factors of individuals (decisions tailored to patients; Primary Care Physician (PCP) consultation style; care planning towards an agreed goal of care), external factors within the environment or context of encounter (patient access to healthcare; organizational structures acting as barriers), and relationship-based factors (collaborative care planning; decisions within a dynamic patient clinician relationship) all influence care planning decisions. There are other important findings which have broader relevance to the literature such as the ongoing separation of physical and mental health which persist even within integrated care systems, GPs continue to prioritize continuity of care and that organizational barriers are reported as factors in clinician decision-making for patients. More broadly, the work has proved valuable in extending previously reported findings surrounding care coordination, and limitation of current guidelines for patients with complex multimorbidity. Work-load in general practice is increasing due to an ageing population, increasing prevalence of multimorbidity and polypharmacy, and transfer of clinical activities from secondary to primary care. The future for GPs is more complexity in the clinic room, understanding how GPs make decisions and how this can be supported is crucial for the sustainability for general practice.

My Goals Are Not Their Goals: Barriers and Facilitators to Delivery of Patient-Centered Care for Patients with Multimorbidity

BACKGROUND

Patient-centered care reflecting patient preferences and needs is integral to high-quality care. Individualized care is important for psychosocially complex or high-risk patients with multiple chronic conditions (i.e., multimorbidity), given greater potential risks of interventions and reduced benefits. These patients are increasingly prevalent in primary care. Few studies have examined provision of patient-centered care from the clinician perspective, particularly from primary care physicians serving in integrated, patient-centered medical home settings within the US Veterans Health Administration.

OBJECTIVE

We sought to clarify facilitators and barriers perceived by primary care physicians in the Veterans Health Administration to delivering patient-centered care for high-risk or complex patients with multimorbidity.

DESIGN

We conducted semi-structured telephone interviews from April to July 2020 among physicians across 20 clinical sites. Findings were analyzed with deductive content analysis based on conceptual models of patient-centeredness and hierarchical factors affecting care delivery.

PARTICIPANTS

Of 23 physicians interviewed, most were female (n = 14/23, 61%), serving in hospital-affiliated outpatient clinics (n = 14/23, 61%). Participants had a mean of 21 (SD = 11.3) years of experience.

KEY RESULTS

Facilitators included the following: effective physician-patient communication to individualize care, prioritize among multiple needs, and elicit goals to improve patient engagement; access to care, enabled by interdisciplinary teams, and dictating personalized care planning; effortful but worthwhile care coordination and continuity; meeting complex needs through effective teamwork; and integrating medical and non-medical care aspects in recognition of patients' psychosocial contexts. Barriers included the following: intra- and interpersonal (e.g., perceived patient reluctance to engage in care); organizational (e.g., limited encounter time); and community or policy impediments (e.g., state decisional capacity laws) to patient-centered care.

CONCLUSIONS

Physicians perceived individual physician-patient interactions were the greatest facilitators or barriers to patient-centered care. Efforts to increase primary care patient-centeredness for complex or high-risk patients with multimorbidity could focus on targeting physician-patient communication and reducing interpersonal conflict.

Consensus elements for observational research on COVID-19-related long-term outcomes

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and its long-term outcomes may be jointly caused by a wide range of clinical, social, and economic characteristics. Studies aiming to identify mechanisms for SARS-CoV-2 morbidity and mortality must measure and account for these characteristics to arrive at unbiased, accurate conclusions. We sought to inform the design, measurement, and analysis of longitudinal studies of long-term outcomes among people infected with SARS-CoV-2. We fielded a survey to an interprofessional group of clinicians and scientists to identify factors associated with SARS-CoV-2 infection and subsequent outcomes. Using an iterative process, we refined the resulting list of factors into a consensus causal diagram relating infection and 12-month mortality. Finally, we operationalized concepts from the causal diagram into minimally sufficient adjustment sets using common medical record data elements. Total 31 investigators identified 49 potential risk factors for and 72 potential consequences of SARS-CoV-2 infection. Risk factors for infection with SARS-CoV-2 were grouped into five domains: demographics, physical health, mental health, personal social, and economic factors, and external social and economic factors. Consequences of coronavirus disease 2019 (COVID-19) were grouped into clinical consequences, social consequences, and economic consequences. Risk factors for SARS-CoV-2 infection were developed into a consensus directed acyclic graph for mortality that included two minimally sufficient adjustment sets. We present a collectively developed and iteratively refined list of data elements for observational research in SARS-CoV-2 infection and disease. By accounting for these elements, studies aimed at identifying causal pathways for long-term outcomes of SARS-CoV-2 infection can be made more informative.

Primary Care Physician Perspectives on the Influence of Patient Values, Health Priorities, and Preferences on Clinical Decision-Making for Complex Patients with Multimorbidity: A Qualitative Study

Introduction

The prevalence of patients with multimorbidity (ie, multiple chronic conditions) is increasing. Clinical decision-making guided by patients' values, health priorities and goals, and treatment preferences is particularly important in the context of interacting diseases and psychosocial needs. Physicians face challenges incorporating patient perspectives into care plans. We examined primary care physician (PCP) views on the influence of patients' values, health priorities and goals, and preferences on clinical decisions for patients with multimorbidity and increased psychosocial complexity.

Methods

We conducted semi-structured telephone interviews with 23 PCPs within patient-centered medical home teams in a nationally integrated health system in the United States between May and July 2020. Data were analyzed via thematic analysis with deductive and inductive coding.

Results

Three major themes emerged: 1. Patient personal values were rarely explicitly discussed in routine clinical encounters but informed more commonly discussed concepts of patient priorities, goals, and preferences; 2. Patient values, health priorities and goals, and preferences were sources of divergent views about care plans between healthcare teams, patients, and families; 3. Physicians used explicit strategies to communicate and negotiate about patient values, health priorities and goals, and preferences when developing care plans, including trust-building; devoting extra effort to individualizing care; connecting patient values to healthcare recommendations; deliberate elicitation and acknowledgement of patient concerns; providing "space" for patient perspectives; incorporating family into care planning; pairing physician to patient priorities; and collaborative teamwork.

Conclusion

Primary care physicians perceive patient values, health priorities and goals, and preferences as influential during clinical decision-making for complex patients with multimorbidity. Participants used concrete strategies to negotiate alignment of these aspects when physician-patient divergence occurred. While rarely discussed directly in clinical encounters, personal values affected patient health priorities, goals, and preferences during care planning, suggesting a clinical role for more deliberate elicitation and discussion of patient values for this population.

Costs of multimorbidity: a systematic review and meta-analyses

BACKGROUND

Multimorbidity is a rising global phenomenon, placing strains on countries' population health and finances. This systematic review provides insight into the costs of multimorbidity through addressing the following primary and secondary research questions: What evidence exists on the costs of multimorbidity? How do costs of specific disease combinations vary across countries? How do multimorbidity costs vary across disease combinations? What "cost ingredients" are most commonly included in these multimorbidity studies?

METHODS

We conducted a systematic review (PROSPERO: CRD42020204871) of studies published from January 2010 to January 2022, which reported on costs associated with combinations of at least two specified conditions. Systematic string-based searches were conducted in MEDLINE, The Cochrane Library, SCOPUS, Global Health, Web of Science, and Business Source Complete. We explored the association between costs of multimorbidity and country Gross Domestic Product (GDP) per capita using a linear mixed model with random intercept. Annual mean direct medical costs per capita were pooled in fixed-effects meta-analyses for each of the frequently reported dyads. Costs are reported in 2021 International Dollars (I$).

RESULTS

Fifty-nine studies were included in the review, the majority of which were from high-income countries, particularly the United States. (1) Reported annual costs of multimorbidity per person ranged from I$800 to I$150,000, depending on disease combination, country, cost ingredients, and other study characteristics. (2) Our results further demonstrated that increased country GDP per capita was associated with higher costs of multimorbidity. (3) Meta-analyses of 15 studies showed that on average, dyads which featured Hypertension were among the least expensive to manage, with the most expensive dyads being Respiratory and Mental Health condition (I$36,840), Diabetes and Heart/vascular condition (I$37,090), and Cancer and Mental Health condition in the first year after cancer diagnosis (I$85,820). (4) Most studies reported only direct medical costs, such as costs of hospitalization, outpatient care, emergency care, and drugs.

CONCLUSIONS

Multimorbidity imposes a large economic burden on both the health system and society, most notably for patients with cancer and mental health condition in the first year after cancer diagnosis. Whether the cost of a disease combination is more or less than the additive costs of the component diseases needs to be further explored. Multimorbidity costing studies typically consider only a limited number of disease combinations, and few have been conducted in low- and middle-income countries and Europe. Rigorous and standardized methods of data collection and costing for multimorbidity should be developed to provide more comprehensive and comparable evidence for the costs of multimorbidity.

Scope of Use and Effectiveness of Dietary Interventions for Improving Health-Related Outcomes in Veterans: A Systematic Review

Military veterans often have numerous physical and mental health conditions and can face unique challenges to intervention and management. Dietary interventions can improve the outcomes in many health conditions. This study aimed to evaluate the scope of health conditions targeted with dietary interventions and the effectiveness of these interventions for improving health-related outcomes in veterans. A systematic literature review was performed following PRISMA guidelines to identify and evaluate studies related to veterans and dietary interventions. Five electronic databases were searched, identifying 2669 references. Following screening, 35 studies were evaluated, and 18 were related to a US national veteran weight-loss program. The included studies were critically appraised, and the findings were narratively synthesized. Study designs ranged from randomised controlled trials to cohort studies and were predominantly U.S. based. The intervention durations ranged from one to 24 months. The mean subject age ranged from 39.0 to 69.7 years, with often predominantly male participants, and the mean body mass index ranged from 26.4 to 42.9 kg/m². Most dietary interventions for veterans were implemented in populations with overweight/obesity or chronic disease and involved single dietary interventions or dietary components of holistic lifestyle interventions. The most common primary outcome of interest was weight loss. The success of dietary interventions was generally moderate, and barriers included poor compliance, mental health conditions and large drop-out rates. The findings from this review illustrate the need for further refinement of dietary and lifestyle interventions for the management of veterans with chronic health conditions.

Medication Adherence Among Patients with Multimorbidity in the United Arab Emirates

Background

Multimorbidity, defined as having two or more chronic diseases, has a major impact on public health and Sustainable Development Goals (SDG). This study aims to assess the prevalence of medication adherence and associated factors among patients with multimorbidity.

Methods

A questionnaire-based, cross-sectional survey was conducted by a trained interviewer across patients with multimorbidity attending outpatient clinics in two tertiary referral hospitals in the United Arab Emirates (UAE). Demographic and social variables and the outcome (self-reported adherence to long-term medication) were measured using the General Medication Adherence Scale (GMAS). Multiple logistic regression was used to assess medication adherence and associated factors.

Results

From a total of 630 participants included in this study, the estimated prevalence of high medication adherence is 78.57% (±1.63478) with a 95% confidence interval (CI) [75.19, 81.61]. The odds of high medication adherence increased with age. The odds of high medication adherence for patients aged 66 years and older than those aged 19-35 years is adjusted odds ratio (AOR) = 3.880, with a 95% CI [1.124, 13.390]. Patients with income more than 50,000 had the odds, AOR = 5.169 with a 95% CI [1.282, 20.843], compared to those earning less than 10,000 Dirhams (AED). Patients aged 36-65 with health insurance coverage had higher medication adherence than groups on the other end. The number of current medications is significantly (p-value = 0.027) associated with high medication adherence with the odds of high medication adherence, AOR = 4.529 with a 95% CI [1.184, 17.326], the highest for those currently taking four medications.

Conclusion

This study highlights younger population having multimorbidity in the context of an increasing life expectancy and suboptimal therapeutic outcomes. Furthermore, the study highlights multimorbidity is associated with low medication adherence and out-of-pocket payment, and non-availability of insurance is a major hindrance to medication adherence.

Risk from delayed or missed care and non-COVID-19 outcomes for older patients with chronic conditions during the pandemic

Background

During the COVID‐19 pandemic, patients with chronic illnesses avoided regular medical care, raising concerns about long‐term complications. Our objective was to identify a population of older patients with chronic conditions who may be at risk from delayed or missed care (DMC) and follow their non‐COVID outcomes during the pandemic.

Methods

We used a retrospective matched cohort design using Medicare claims and electronic health records at a large health system with community and academic clinics. Participants included 14,406 patients over 65 years old with two or more chronic conditions who had 1 year of baseline data and up to 9 months of postpandemic follow‐up from March 1, 2019 to December 31, 2020; and 14,406 matched comparison patients from 1 year prior. Risk from DMC was defined by 13 indicators, including chronic conditions, frailty, disability affecting the use of telehealth, recent unplanned acute care, prior missed outpatient care, and social determinants of health. Outcomes included mortality, inpatient events, Medicare payments, and primary care and specialty care visits (in‐person and telehealth).

Results

A total of 25% of patients had four or more indicators for risk from DMC. Per 1000 patients annually, those with four or more indicators had increased mortality of 19 patients (95% confidence interval, 4 to 32) and decreased utilization, including unplanned events (−496 events, −611 to −381) and primary care visits (−1578 visits, −1793 to −1401).

Conclusions

Older patients who had four or more indicators for risk from DMC had higher mortality and steep declines in inpatient and outpatient utilization during the pandemic.

Analysis of multiple chronic disease characteristics in South Koreans by age groups using association rules analysis

The prevalence of MCD (multiple chronic disease) is increasing due to increased life expectancies and aging populations. Individual and socioeconomic burdens of MCD are also increasing. To reduce these burdens, it is necessary to establish policies to prevent MCD; therefore, it is important to understand the characteristics of MCD in the current population. In this study, the combinations of MCD that affect hypertension, which has the highest prevalence, were examined according to different age groups. The combinations of diseases were identified utilizing association rules analysis, using the Community Health Survey as the raw data. Two association rules were determined in young adult group, 18 in the middle-aged group, and 30 in the senior group, showing that the number of rules increases with age. Association rules of this study mean that combined chronic diseases are highly associated with hypertension. Then logistic regression analysis was performed on the MCD combinations with highest lift value in each age group to identify relationships between health behavior and MCD combinations. Especially, alcohol consumption was found to be a common factor affecting MCD prevalence in three combinations. On the contrary, sleep habit did not have a statistically significant influence on any combination.

Cross-cultural adaptation and validation of the caregiver contribution to self-care of chronic illness inventory in China: a cross-sectional study

OBJECTIVE

Caregiver contribution (CC) is important for the self-care behaviors of chronic disease individuals, as it could enhance patient outcomes. Therefore, it is necessary to assess this CC by using a good validity and reliability instrument. The Caregiver Contribution to Self-Care Chronic Illness Inventory (CC-SC-CII) was designed to assess CC to self-care behaviors of patients with chronic illness in Italy. However, it was unclear whether this tool had sound psychometrics properties in the context of Chinese culture. Therefore, we performed the cross-cultural adaption of the CC-SC-CII and we tested its psychometric properties among Chinese caregivers of patients with chronic disease.

DESIGN

A cross-sectional observational design.

SETTINGS

Participants were recruited from communities and institutions in Pingdingshan, Henan Province, China.

PARTICIPANTS

301 caregivers of care recipients with chronic disease completed the Chinese version of the CC-SC-CII (C-CC-SC-CII).

PRIMARY AND SECONDARY OUTCOME MEASURES

The content validity index of items (I-CVI), the scale content validity index-average (S-CVI/Ave), exploratory factor analysis, confirmatory factor analysis (CFA), internal consistency and item analysis were tested.

RESULTS

The range of I-CVI was between 0.833 and 1.00, and the score of S-CVI was 0.991. In CFA, the C-CC to self-care monitoring scale had satisfactory fit indices. However, the C-CC to self-care maintenance and management scales had unsupported fit indices. The reliability coefficients of C-CC-SC-CII were 0.792, 0.880 and 0.870 for its three scales. Item-total correlations were all over 0.590. Test-retest reliability showed that the range of intraclass correlation coefficients was from 0.728 to 0.783.

CONCLUSION

The C-CC-SC-CII has sound psychometrics characteristics and is a culturally appropriate and reliable instrument for assessing CC to the self-care behaviours of patients with chronic disease in China.

Functional limitations in people with multimorbidity and the association with mental health conditions: Baseline data from the Canadian Longitudinal Study on Aging (CLSA)

INTRODUCTION

Increasing multimorbidity is often associated with declining physical functioning, with some studies showing a disproportionate impact on functioning when mental health conditions are present. More research is needed because most multimorbidity studies exclude mental health conditions.

OBJECTIVES

This study aims to improve our understanding of the association between functional limitation and multimorbidity, including a comparison of those with multimorbidity that includes versus excludes mental health conditions.

METHODS

This is a population-based, cross-sectional analysis of data from The Canadian Longitudinal Study on Aging. Functional limitation was defined as the presence of any of 14 activities of daily living (ADLs) or instrumental activities of daily living (IADLs). Multimorbidity, measured by the number of chronic conditions, included mood and anxiety disorders. Logistic regression explored the association between multimorbidity (with and without mental health conditions) and functional limitation. Factor analysis identified common condition clusters to help understand clinical complexity in those with mood/anxiety disorders and the potential influences on functional limitation.

RESULTS

There were 51,338 participants, with a similar proportion of men and women (49% versus 51%) and 42% age 65 years or older. Fifteen percent (15%) had no chronic conditions and 17% had 5+. Ten percent (10%) reported at least one ADL or IADL limitation. Odds ratios (ORs) for functional limitation increased with multimorbidity and were generally higher for those with versus without mental health conditions (e.g., ORs from 1 to 5+ chronic conditions increased 1.9 to 15.8 for those with mood/anxiety disorders versus 1.8 to 10.2 for those without). Factor analysis showed that mood/anxiety conditions clustered with somatic conditions (e.g., migraines, bowel/gastrointestinal disorders).

CONCLUSION

This study found higher odds of functional limitation for those with multimorbidity that included versus excluded mental health conditions, at all levels of multimorbidity. It highlights the need for concurrent management of mental and physical comorbidities to prevent functional limitations and future decline. This approach is aligned with the NICE clinical assessment and management guidelines for people with multimorbidity.

Disproportionate multimorbidity among veterans in middle age

BACKGROUND

Little is known about the prevalence of multimorbidity among middle-aged veterans. Multimorbidity holds implications for planning for a population with high health care utilization, poor quality of life and marked need for interdisciplinary care.

METHODS

The current study used the US 2017 Behavior Risk Factor Surveillance System to measure multimorbidity in three ways: (1) reporting two or more health conditions, (2) reporting two or more conditions controlling for demographic characteristics (e.g. income) and health risk behaviors (e.g. smoking) and (3) a weighted index using health-related quality of life.

RESULTS

After age 25, veterans' risk for multimorbidity increased across all age groups. The increased odds of reporting multimorbidity was highest when comparing veterans aged 35-44 to non-veterans of the same ages. Veterans aged 35-44 are 50% (adjusted odds ratios (AOR) 1.50, 95% confidence interval (CI) 1.16, 1.94) to 80% (AOR 1.80, 95% CI 1.46, 2.23) more likely to report multimorbidity when compared with same aged non-veterans.

CONCLUSIONS

Younger veterans may benefit from comprehensive interdisciplinary services to aid in the treatment of multiple medical conditions. Failure to account for the impact of chronic conditions on quality of life may lead to an underestimate of the health care needs of veterans across the lifespan.

Achieving Whole Health: A Preliminary Study of TCMLH, a Group-Based Program Promoting Self-Care and Empowerment Among Veterans

OBJECTIVE

An emerging literature suggests patients with chronic illnesses can benefit from integrated, person-centric approaches to health care, including group-based programs. However, much of the research in this area is disease specific. The objective of this study was to collect preliminary evidence on the efficacy of Taking Charge of My Life and Health (TCMLH), a Whole Health group-based program that emphasizes self-care and empowerment on the overall health and well-being of veterans, a population burdened with high rates of multiple chronic conditions.

METHOD

Self-reported outcomes, including standardized survey measures, were collected at pretest, posttest, and 2-month follow-up from 77 participants across 15 groups at four VA sites. Random intercept mixed-model regressions were used to analyze data.

RESULTS

Results from this initial study showed high satisfaction with the program and facilitators, and high attendance. There were significant pre-post gains in self-care attitudes and behaviors, patient motivation, meaning and purpose, mental health, perceived stress, goal progress, and goal-specific hope. Outcomes were maintained at 2-month follow-up for patient motivation, perceived stress, goal-specific hope, and goal progress. Significant gains were observed in health care empowerment and physical health from pretest to follow-up.

CONCLUSIONS

Preliminary findings support the efficacy of TCMLH, a Whole Health group-based program that emphasizes patient empowerment, self-care practices, and peer support. Future research priorities include a rigorous evaluation with a larger sample size and control group to assess effectiveness.

Subgroups of High-Risk Veterans Affairs Patients Based on Social Determinants of Health Predict Risk of Future Hospitalization

OBJECTIVE

Population segmentation has been recognized as a foundational step to help tailor interventions. Prior studies have predominantly identified subgroups based on diagnoses. In this study, we identify clinically coherent subgroups using social determinants of health (SDH) measures collected from Veterans at high risk of hospitalization or death.

STUDY DESIGN AND SETTING

SDH measures were obtained for 4684 Veterans at high risk of hospitalization through mail survey. Eleven self-report measures known to impact hospitalization and amenable to intervention were chosen a priori by the study team to identify subgroups through latent class analysis. Associations between subgroups and demographic and comorbidity characteristics were calculated through multinomial logistic regression. Odds of 180-day hospitalization were compared across subgroups through logistic regression.

RESULTS

Five subgroups of high-risk patients emerged-those with: minimal SDH vulnerabilities (8% hospitalized), poor/fair health with few SDH vulnerabilities (12% hospitalized), social isolation (10% hospitalized), multiple SDH vulnerabilities (12% hospitalized), and multiple SDH vulnerabilities without food or medication insecurity (10% hospitalized). In logistic regression, the "multiple SDH vulnerabilities" subgroup had greater odds of 180-day hospitalization than did the "minimal SDH vulnerabilities" reference subgroup (odds ratio: 1.53, 95% confidence interval: 1.09-2.14).

CONCLUSION

Self-reported SDH measures can identify meaningful subgroups that may be used to offer tailored interventions to reduce their risk of hospitalization and other adverse events.

Structure and Distribution of Health Care Costs across Age Groups of Patients with Multimorbidity in Lithuania

Background. Patients with multimorbidity account for ever-increasing healthcare resource usage and are often summarised as big spenders. Comprehensive analysis of health care resource usage in different age groups in patients with at least two non-communicable diseases is still scarce, limiting the quality of health care management decisions, which are often backed by limited, small-scale database analysis. The health care system in Lithuania is based on mandatory social health insurance and is covered by the National Health Insurance Fund. Based on a national Health Insurance database. The study aimed to explore the distribution, change, and interrelationships of health care costs across the age groups of patients with multimorbidity, suggesting different priorities at different age groups. Method. The study identified all adults with at least one chronic disease when any health care services were used over a three-year period between 2012 and 2014. Further data analysis excluded patients with single chronic conditions and further analysed patients with multimorbidity, accounting for increasing resource usage. The costs of primary, outpatient health care services; hospitalizations; reimbursed and paid out-of-pocket medications were analysed in eight age groups starting at 18 and up to 85 years and over. Results. The study identified a total of 428,430 adults in Lithuania with at least two different chronic diseases from the 32 chronic disease list. Out of the total expenditure within the group, 51.54% of the expenses were consumed for inpatient treatment, 30.90% for reimbursed medications. Across different age groups of patients with multimorbidity in Lithuania, 60% of the total cost is attributed to the age group of 65–84 years. The share in the total spending was the highest in the 75–84 years age group amounting to 29.53% of the overall expenditure, with an increase in hospitalization and a decrease in outpatient services. A decrease in health care expenses per capita in patients with multimorbidity after 85 years of age was observed. Conclusions. The highest proportion of health care expenses in patients with multimorbidity relates to hospitalization and reimbursed medications, increasing with age, but varies through different services. The study identifies the need to personalise the care of patients with multimorbidity in the primary-outpatient setting, aiming to reduce hospitalizations with proactive disease management.

Relationship Between Chronic Conditions and Balance Disorders in Outpatients with Dizziness: A Hospital-Based Cross-Sectional Study

Background

Balance dysfunction is common in adult outpatients with dizziness, especially those who are older, which can lead to catastrophic outcomes such as falls. The aim of this study was to investigate the association between chronic conditions and balance disorders in patients with dizziness, especially those who are elderly.

Material/Methods

A cross-sectional study was conducted in adult outpatients diagnosed with dizziness referred to the Department of Otolaryngology at Beijing Tongren Hospital from September 2017 to August 2018. All of the patients completed a self-administered, structured questionnaire. Demographic data and information on history of chronic conditions were collected and the patients were divided into 2 groups based on whether their balance was normal or abnormal.

Results

Three hundred and thirty-two patients were included in this study, 168 in the normal balance group and 164 in the abnormal balance group. The incidence of chronic conditions, including hypertension and diabetes, in the abnormal balance group was higher than that in the normal balance group (all P<0.05). In subgroup analysis based on age, in those who were aged ≥60 years, the prevalence of chronic diseases was higher in the abnormal balance group than in the normal balance group (P=0.002), while there was no difference in age between the groups with abnormal and normal balance. Hypertension (OR: 2.268; 95%CI: 1.038–4.957; P<0.05) was a risk factor for balance disorders in elderly patients rather than those who were younger (P>0.05).

Conclusions

Our results show that chronic conditions are associated with balance function in older patients with dizziness. Thus, specialists should consider chronic conditions, especially hypertension, in elderly patients with dizziness.

A machine learning approach to identify distinct subgroups of veterans at risk for hospitalization or death using administrative and electronic health record data

Background

Identifying individuals at risk for future hospitalization or death has been a major priority of population health management strategies. High-risk individuals are a heterogeneous group, and existing studies describing heterogeneity in high-risk individuals have been limited by data focused on clinical comorbidities and not socioeconomic or behavioral factors. We used machine learning clustering methods and linked comorbidity-based, sociodemographic, and psychobehavioral data to identify subgroups of high-risk Veterans and study long-term outcomes, hypothesizing that factors other than comorbidities would characterize several subgroups.

Methods and findings

In this cross-sectional study, we used data from the VA Corporate Data Warehouse, a national repository of VA administrative claims and electronic health data. To identify high-risk Veterans, we used the Care Assessment Needs (CAN) score, a routinely-used VA model that predicts a patient’s percentile risk of hospitalization or death at one year. Our study population consisted of 110,000 Veterans who were randomly sampled from 1,920,436 Veterans with a CAN score≥75^th percentile in 2014. We categorized patient-level data into 119 independent variables based on demographics, comorbidities, pharmacy, vital signs, laboratories, and prior utilization. We used a previously validated density-based clustering algorithm to identify 30 subgroups of high-risk Veterans ranging in size from 50 to 2,446 patients. Mean CAN score ranged from 72.4 to 90.3 among subgroups. Two-year mortality ranged from 0.9% to 45.6% and was highest in the home-based care and metastatic cancer subgroups. Mean inpatient days ranged from 1.4 to 30.5 and were highest in the post-surgery and blood loss anemia subgroups. Mean emergency room visits ranged from 1.0 to 4.3 and were highest in the chronic sedative use and polysubstance use with amphetamine predominance subgroups. Five subgroups were distinguished by psychobehavioral factors and four subgroups were distinguished by sociodemographic factors.

Conclusions

High-risk Veterans are a heterogeneous population consisting of multiple distinct subgroups–many of which are not defined by clinical comorbidities–with distinct utilization and outcome patterns. To our knowledge, this represents the largest application of ML clustering methods to subgroup a high-risk population. Further study is needed to determine whether distinct subgroups may benefit from individualized interventions.

Correlates of Concurrent Morbid Obesity and Tobacco Use Disorder Nationally in the Veterans Health Administration

The aim of this study was to examine health, demographic, and service utilization characteristics of veterans with multimorbid tobacco use disorder (TUD) and morbid obesity compared to those with either condition alone. Methods: Health record data were extracted from the computerized patient record system of the Veterans Health Administration (VHA; October 1, 2011 to September 30, 2012). Bivariate and multivariate logistic regression models were used to compare veterans with both TUD and morbid obesity (body mass index [BMI] ≥ 40 kg/m²) to veterans with each condition alone on a range of demographic, health, and service utilization outcome variables that also were extracted from the VHA administrative record. Results: Veterans with both morbid obesity and TUD showed higher rates of medical and psychiatric comorbidity than did veterans with either condition alone. However, while veterans with TUD and morbid obesity showed higher rates of comorbid substance use disorders than veterans with morbid obesity alone, veterans with both conditions showed substantially lower rates of substance use disorders than those with TUD alone. Conclusions: Veterans with co-occurring morbid obesity and TUD appear to be at greater risk for medical disease and psychiatric conditions. The unexpected finding that veterans with TUD alone had more concurrent substance use disorders than veterans with both TUD and morbid obesity suggest the possibility that overeating may be a substitute for substance use in the context of TUD. The multimorbidity profile described here may suggest unique treatment needs for individuals with both TUD and morbid obesity. Highlights Medical multimorbidities predict additional health conditions and poorer outcomes. Obesity and tobacco use may share common underlying vulnerabilities. Veterans with both conditions showed higher rates of certain multimorbidities. Obesity may protect against substance use in tobacco users.

Physician Specialty and Office Visits Made by Adults With Diagnosed Multiple Chronic Conditions: United States, 2014-2015

Objectives

Adults with multiple chronic conditions (MCCs; ≥2 chronic conditions) account for a substantial number of visits to health care providers. The complexity of a patient’s care, including the number of chronic conditions, may differ by physician specialty. The objectives of this study were to (1) examine differences in physician office visits among adults with MCCs by physician specialty and (2) identify the types of MCC dyads (combinations of 2 chronic conditions) most common among visits to office-based physicians.

Methods

We used data from the 2014-2015 National Ambulatory Medical Care Survey (unweighted analytic sample, n = 61 682), a nationally representative survey of physician office–based ambulatory visits, to examine differences in physician office visits among adults with MCCs by physician specialty. We also identified the most commonly observed MCC dyads among these visits.

Results

During 2014-2015, 40.0% of physician office visits were made by adults with MCCs. Compared with visits for all specialties combined (40.0%), a significantly higher percentage of physician office visits among adults with MCCs were to specialists in cardiovascular disease (74.7%) and internal medicine (57.6%). For all physician specialties except psychiatry, the MCC dyads of hyperlipidemia and hypertension and diabetes and hypertension were among the most commonly observed MCC dyads among visits made by adults with MCCs.

Conclusions

Awareness of these findings may help specialists improve care for adults with MCCs. The recognition among physicians of common MCC dyads is relevant to the care management of persons with MCCs.

Measuring multimorbidity series. An overlooked complexity - Comparison of self-report vs. administrative data in community-living adults: Paper 3. Agreement across data sources and implications for estimating associations with health service use

OBJECTIVE

The objective of this study is to describe agreement between administrative and self-report data on the number and type of chronic conditions (CCs) and determine whether associations between CC count and health service use differ by data source.

STUDY DESIGN AND SETTING

We linked Canadian Community Health Survey and administrative data for a cohort of adults aged 45+ years in Ontario and identified 12 CCs from both data sources. Agreement was described by count and constituent CCs. We estimated associations between CC count (self-report and administrative data) and health service use (administrative data only) over 1 year.

RESULTS

Among 71,317 adults, 26.9% showed agreement on both count and constituent CCs but agreement declined with increasing CCs. Health service use increased with CC count but the association was stronger when CCs were measured with administrative data. For example, when measured with administrative data, the odds of a general practitioner visit for 5+ CCs vs. none was 20.3 (95% CI 20.0-20.5) but when using self-report data, the estimate was 8.0 (95% CI 7.8-8.2).

CONCLUSION

Agreement on the number of CCs was low and resulted in different estimates on the association with health service use, illustrating the challenges in CC measurement and the ability to interpret the effects on outcomes.

Heart Failure Dashboard Design and Validation to Improve Care of Veterans

BACKGROUND

Early electronic identification of patients at the highest risk for heart failure (HF) readmission presents a challenge. Data needed to identify HF patients are in a variety of areas in the electronic medical record (EMR) and in different formats.

OBJECTIVE

The purpose of this paper is to describe the development and data validation of a HF dashboard that monitors the overall metrics of outcomes and treatments of the veteran patient population with HF and enhancing the use of guideline-directed pharmacologic therapies.

METHODS

We constructed a dashboard that included several data points: care assessment need score; ejection fraction (EF); medication concordance; laboratory tests; history of HF; and specified comorbidities based on International Classification of Disease (ICD), ninth and tenth codes. Data validation testing with user test scripts was utilized to ensure output accuracy of the dashboard. Nine providers and key senior management participated in data validation.

RESULTS

A total of 43 medical records were reviewed and 66 HF dashboard data discrepancies were identified during development. Discrepancies identified included: generation of multiple EF values on a few patients, missing or incorrect ICD codes, laboratory omission, incorrect medication issue dates, patients incorrectly noted as nonconcordant for medications, and incorrect dates of last cardiology appointments. Continuous integration and builds identified defects-an important process of the verification and validation of biomedical software. Data validation and technical limitations are some challenges that were encountered during dashboard development. Evaluations by testers and their focused feedback contributed to the lessons learned from the challenges.

CONCLUSION

Continuous refinement with input from multiple levels of stakeholders is crucial to development of clinically useful dashboards. Extraction of all relevant information from EMRs, including the use of natural language processing, is crucial to development of dashboards that will help improve care of individual patients and populations.

"The strategies are the same, the problems may be different": a qualitative study exploring the experiences of healthcare and service providers with medication therapy management for individuals with spinal cord injury/dysfunction

Background

Persons with spinal cord injury/dysfunction (SCI/D) often take multiple medications to treat their secondary complications and chronic conditions (multimorbidity). Multiple healthcare and service providers are often involved in care, which can result in increased risk of fragmentation of care. Optimal medication therapy management (MTM) is essential to ensure therapeutic benefit from medication regimens. However, little is known about the experiences of providers in supporting persons with SCI/D with MTM.

Methods

Telephone interviews were conducted to explore healthcare and service providers’ experiences with MTM for persons with SCI/D. Participants were recruited through clinical organizations and researchers’ personal contacts. Participants were purposefully selected for diversity in profession and were required to be English speaking and to have provided care to at least one person with SCI/D. The qualitative interviews followed a semi-structured interview guide. Data display matrices were used in a constant comparative process for descriptive and interpretive analysis.

Results

Thirty-two interviews were conducted from April to December 2018. Each profession had distinct views on their roles in facilitating MTM for persons with SCI/D, which aligned with their respective scopes of practice. Shared provider tasks included tailoring medications, providing education, and exploring medication alternatives. Most participants felt that the care they provided for persons with SCI/D was similar to the care that they provided to other patients, with some differences relating to the physical limitations and medical complexity associated with SCI/D. Five factors were identified that impacted participants’ abilities to provide MTM for persons with SCI/D: patient self-management skills, provider knowledge and confidence, provider-patient relationships, interprofessional collaboration, and provider funding models including the use of technology-supported consultations.

Conclusion

While participants described commonalities in the barriers and enablers associated with providing MTM to persons with SCI/D and other populations, there were unique considerations identified. These SCI/D-specific considerations resulted in recommendations for improvements in MTM for this population. Future research should include perspectives from persons with SCI/D.

A longitudinal analysis of tobacco use in younger and older U.S. veterans

United States (U.S.) veterans are prone to higher rates of smoking and smoking-related disease. We describe the prevalence of cigarette and non-cigarette product use and determine longitudinal predictors of tobacco use transitions in this vulnerable population.

Data are from Waves 1 (2013–2014) and 2 (2014–2015) of the adult cohort in the Population Assessment of Tobacco and Health. Wave 1 prevalence was calculated for past 30-day use of all queried tobacco products, and compared by veteran status. Weighted multinomial logistic regression was used to determine predictors—demographics, substance use, and physical and psychological comorbidities—of tobacco use transitions (continued use, initiation, and cessation) among veterans.

Compared to non-veterans, use of nearly all tobacco products was significantly higher among veterans and was highest among younger veterans. Compared to continued nonusers, continued users were more likely to: be of younger age (OR = 0.95, 95% CI: 0.95–0.96), have poorer physical health (OR = 1.58, 95% CI: 1.22–2.06) and mental health (OR = 1.48, 95% CI: 1.18–1.85), report substance use (OR = 1.79, 95% CI: 1.21–2.64), and report problematic alcohol use (OR = 4.23, 95% CI: 2.38–7.52) and were less likely to be female (OR = 0.57, 95% CI: 0.35–0.93). Compared to continued nonusers, initiators were more likely to report problematic alcohol use (OR = 8.63, 95% CI: 3.79–19.63), and those in the cessation category were more likely to be of younger age (OR = 0.97, 95% CI: 0.95–0.99).

Cigarette and non-cigarette use is especially prevalent among young veterans, so prevention should begin during military service. Tobacco cessation programs should be tailored for this population, incorporating aspects related to concomitant health conditions.

Comparing the prognostic value of geriatric health indicators: a population-based study

BACKGROUND

The identification of individuals at increased risk of poor health-related outcomes is a priority. Geriatric research has proposed several indicators shown to be associated with these outcomes, but a head-to-head comparison of their predictive accuracy is still lacking. We therefore aimed to compare the accuracy of five geriatric health indicators in predicting different outcomes among older persons: frailty index (FI), frailty phenotype (FP), walking speed (WS), multimorbidity, and a summary score including clinical diagnoses, functioning, and disability (the Health Assessment Tool; HAT).

METHODS

Data were retrieved from the Swedish National Study on Aging and Care in Kungsholmen, an ongoing longitudinal study including 3363 people aged 60+. To inspect the accuracy of geriatric health indicators, we employed areas under the receiver operating characteristic curve (AUC) for the prediction of 3-year and 5-year mortality, 1-year and 3-year unplanned hospitalizations (1+), and contacts with healthcare providers in the 6 months before and after baseline evaluation (2+).

RESULTS

FI, WS, and HAT showed the best accuracy in the prediction of mortality [AUC(95%CI) for 3-year mortality 0.84 (0.82-0.86), 0.85 (0.83-0.87), 0.87 (0.85-0.88) and AUC(95%CI) for 5-year mortality 0.84 (0.82-0.86), 0.85 (0.83-0.86), 0.86 (0.85-0.88), respectively]. Unplanned hospitalizations were better predicted by the FI [AUC(95%CI) 1-year 0.73 (0.71-0.76); 3-year 0.72 (0.70-0.73)] and HAT [AUC(95%CI) 1-year 0.73 (0.71-0.75); 3-year 0.71 (0.69-0.73)]. The most accurate predictor of multiple contacts with healthcare providers was multimorbidity [AUC(95%CI) 0.67 (0.65-0.68)]. Predictions were generally less accurate among younger individuals (< 78 years old).

CONCLUSION

Specific geriatric health indicators predict clinical outcomes with different accuracy. Comprehensive indicators (HAT, FI, WS) perform better in predicting mortality and hospitalization. Multimorbidity exhibits the best accuracy in the prediction of multiple contacts with providers.

Four Decades after War: Incident Diabetes among Women Vietnam-Era Veterans in the HealthViEWS Study

OBJECTIVES

We analyzed long-term differences in incident diabetes associated with military service in a warzone among women who served during the Vietnam War era.

METHODS

For HealthViEWS, the largest later-life study of women Vietnam War-era U.S. veterans, a population-based retrospective cohort who served during 1965-1973 completed a health interview in 2011-2012. This cohort included women deployed to Vietnam, near Vietnam, or who served primarily in the United States. We hypothesized a warzone exposure gradient: Vietnam (highest exposure), near Vietnam, and the United States (lowest exposure). We used an extended Cox regression to test for differences in incident diabetes by location of wartime service.

RESULTS

Of 4,503 women in the analysis, 17.7% developed diabetes. Adjusting for demographics and military service characteristics, hazard of incident diabetes was significantly lower initially in the Vietnam group compared with the U.S. group (hazard ratio, 0.33; 95% confidence interval, 0.15-0.69). However, lower diabetes hazard in the Vietnam group was not constant over time; rather, hazard accumulated faster over time in the Vietnam group compared with the U.S. group (hazard ratio, 1.38; 95% confidence interval, 1.11-1.72). No significant difference in diabetes hazard was found between the near Vietnam and U.S. groups. Older age during military service, minority race/ethnicity, and lower military rank were associated with a higher diabetes hazard.

CONCLUSIONS

Women deployed to a warzone might have protective health factors that lower risk for diabetes early in their military career, but delivery systems for long-term health should consider that a lower risk for chronic diseases like diabetes can wane quickly in the decades that follow warzone service.

Multimorbidity among Veterans Diagnosed with PTSD in the Veterans Health Administration Nationally

Over 30% of veterans treated for psychiatric disorders in the Veterans Health Administration (VHA) are diagnosed with Post-Traumatic Stress Disorder (PTSD), with most receiving treatment for war-zone stress they experienced decades previously. We examined psychiatric multimorbidity among these patients and consider its implications for treatment and research. Using national VHA data from Fiscal Year 2012 on all veterans diagnosed with PTSD, we compared those with PTSD only to those with one, two, and three or more concurrent (non-substance use) psychiatric disorders. Comparisons of these four groups on sociodemographic characteristics, medical and substance use co-morbidities, health service use, and psychotropic prescription fills were conducted using bi-variate and ordinal logistic regression methods. Of 638,451 veterans diagnosed with PTSD in FY2012, only 29.8% had PTSD alone; 36.7% had one concurrent psychiatric diagnosis, 21.3% had two, and 12.2% had three or more. Anxiety disorder and major depressive disorder were the most common concurrent diagnoses. Veterans with higher levels of multimorbidity were younger, had greater likelihood of recent homelessness, substance use disorder, and diverse medical diagnoses, along with increased mental health and medical service use and greater psychotropic medication use. Psychiatric multimorbidity is highly prevalent among VHA patients diagnosed with PTSD, and may represent an underappreciated and poorly understood clinical complication that poses unique challenges to effective treatment. Clinical attention and both epidemiological and interventional research on multimorbidity in PTSD patients are needed in order to better understand and treat this common but understudied phenomenon.

Coordinating Care Across VA Providers and Settings: Policy and Research Recommendations from VA's State of the Art Conference

Delivering well-coordinated care is essential for optimizing clinical outcomes, enhancing patient care experiences, minimizing costs, and increasing provider satisfaction. The Veterans Health Administration (VA) has built a strong foundation for internally coordinating care. However, VA faces mounting internal care coordination challenges due to growth in the number of Veterans using VA care, high complexity in Veterans' care needs, the breadth and depth of VA services, and increasing use of virtual care. VA's Health Services Research and Development service with the Office of Research and Development held a conference assessing the state-of-the-art (SOTA) on care coordination. One workgroup within the SOTA focused on coordination between VA providers for high-need Veterans, including (1) Veterans with multiple chronic conditions; (2) Veterans with high-intensity, focused, specialty care needs; (3) Veterans experiencing care transitions; (4) Veterans with severe mental illness; (5) and Veterans with homelessness and/or substance use disorders. We report on this workgroup's recommendations for policy and organizational initiatives and identify questions for further research. Recommendations from a separate workgroup on coordinating VA and non-VA care are contained in a companion paper. Leaders from research, clinical services, and VA policy will need to partner closely as they develop, implement, assess, and spread effective practices if VA is to fully realize its potential for delivering highly coordinated care to every Veteran.

Measuring the burden of multimorbidity among Medicare beneficiaries via condition counts and cumulative duration

OBJECTIVE

The study's purpose was to describe the cumulative duration of 19 chronic conditions among Medicare fee-for-service (FFS) beneficiaries and examine variation in total expenditures explained by cumulative duration and condition counts.

DESIGN, SETTING, STUDY DESIGN, AND DATA EXTRACTION

In a retrospective cohort of FFS beneficiaries age ≥68, 2015 Medicare enrollment and claims data (N = 20 124 230) were used to identify the presence or absence of 19 diagnosed chronic conditions, and to construct MCC categories (0-1, 2-3, 4-5, 6+) and cumulative duration of each of 19 conditions from the date of first possible occurrence in claims (1/1/1999) to the end of follow-up (date of death or 12/31/2015). Total Medicare expenditures were estimated using linear models adjusted for demographic characteristics.

PRINCIPAL FINDINGS

Multimorbidity was common (71.7 percent with 2+ conditions). The mean cumulative duration of all 19 conditions was 23.6 person-years, which varied greatly by age and number of conditions. Condition counts were more predictive of Medicare expenditures than cumulative duration (R-squared for continuous measures = 0.461 vs 0.272; R-squared for quartiles = 0.408 vs 0.266).

CONCLUSIONS

The cumulative duration of chronic conditions varied widely for Medicare beneficiaries, especially for those with 6+ conditions, but was less predictive of total expenditures than condition counts.

Measuring the burden of multimorbidity among Medicare beneficiaries via condition counts and cumulative duration

OBJECTIVE

The study's purpose was to describe the cumulative duration of 19 chronic conditions among Medicare fee-for-service (FFS) beneficiaries and examine variation in total expenditures explained by cumulative duration and condition counts.

DESIGN, SETTING, STUDY DESIGN, AND DATA EXTRACTION

In a retrospective cohort of FFS beneficiaries age ≥68, 2015 Medicare enrollment and claims data (N = 20 124 230) were used to identify the presence or absence of 19 diagnosed chronic conditions, and to construct MCC categories (0-1, 2-3, 4-5, 6+) and cumulative duration of each of 19 conditions from the date of first possible occurrence in claims (1/1/1999) to the end of follow-up (date of death or 12/31/2015). Total Medicare expenditures were estimated using linear models adjusted for demographic characteristics.

PRINCIPAL FINDINGS

Multimorbidity was common (71.7 percent with 2+ conditions). The mean cumulative duration of all 19 conditions was 23.6 person-years, which varied greatly by age and number of conditions. Condition counts were more predictive of Medicare expenditures than cumulative duration (R-squared for continuous measures = 0.461 vs 0.272; R-squared for quartiles = 0.408 vs 0.266).

CONCLUSIONS

The cumulative duration of chronic conditions varied widely for Medicare beneficiaries, especially for those with 6+ conditions, but was less predictive of total expenditures than condition counts.

Continuity of care and multiple chronic conditions impact frequent use of outpatient services

This study investigated the association between care continuity and chronic conditions in relation to highly frequent use of outpatient service in order to find constructive suggestions to bring efficient, high-quality care for patients with multiple chronic conditions. The National Health Insurance database was used and 333,294 patients were identified from 2007 to 2009. The continuity of care index indicates the dispersion of a patient's ambulatory visits among providers. Multivariate logistic regression was used to estimate adjusted odds ratios with 95 percent confidence intervals. Continuity of care index was significantly associated with age, sex, urbanization level, socioeconomic status, emergency department visits, hospitalization, psychological disorders, chronic diseases, and catastrophic illness card; those with low continuity of care index were likely to use outpatient care highly frequently. Improving continuity of care is fundamental, and the best way is to advance the practice of family medicine for primary care.

Polysubstance Use Among Veterans in Intensive PTSD Programs: Association With Symptoms and Outcomes Following Treatment

Objective: A distinct group of patients has recently been described who experience polysubstance use disorder characterized by use of multiple addictive substances. This study examines baseline characteristics and longitudinal outcomes of a group of such patients in specialized intensive Veterans Health Administration posttraumatic stress disorder (PTSD) programs and followed 4 months after discharge. Methods: Patients with diagnosed PTSD or subsyndromal PTSD and who used a single substance at baseline were compared to those who used two or three and more than three different addictive substances on measures of PTSD symptom severity and functioning. Comparisons were also adjusted for differences in total days of any substance use and other potentially confounding factors. Patients were reclassified according to the number of substances used at follow-up and again compared on symptoms and functioning. Results: Bivariate analysis of baseline data (N = 8,240) showed frequent polysubstance use (n = 3,695, 44.8% of the sample) and that use of greater numbers of substances was associated with more severe PTSD symptoms as well as more total days of substance use. At follow-up after treatment, 58.2% of the original sample (n = 4,797) was assessed. Polysubstance use was less frequent (n = 756, 15.8% of the follow-up sample), but showed a similar association with more severe symptoms, although differences were attenuated after adjusting for total days of substance use. Conclusions: Polysubstance use, conceptualized within the multimorbidity perspective, is associated with increased severity of PTSD symptoms among veterans with dual diagnoses requiring complex interventions, the evaluation of which will require innovative trial designs.

Using item response theory with health system data to identify latent groups of patients with multiple health conditions

A critical step toward tailoring effective interventions for heterogeneous and medically complex patients is to identify clinically meaningful subgroups on the basis of their comorbid conditions. We applied Item Response Theory (IRT), a potentially useful tool to identify clinically meaningful subgroups, to characterize phenotypes within a cohort of high-risk patients. This was a retrospective cohort study using 68,400 high-risk Veteran’s Health Administration (VHA) patients. Thirty-one physical and mental health diagnosis indicators based on ICD-9 codes from patients’ inpatient, outpatient VHA and VA-paid community care claims. Results revealed 6 distinct subgroups of high-risk patients were identified: substance use, complex mental health, complex diabetes, liver disease, cancer with cardiovascular disease, and cancer with mental health. Multinomial analyses showed that subgroups significantly differed on demographic and utilization variables which underscored the uniqueness of the groups. Using IRT models with clinical diagnoses from electronic health records permitted identification of diagnostic constellations among otherwise undifferentiated high-risk patients. Recognizing distinct patient profiles provides a framework from which insights into medical complexity of high-risk patients can be explored and effective interventions can be tailored.

Improving Team-Based Care Coordination Delivery and Documentation in the Health Record

A template developed at the Atlanta VAMC standardizes and captures data about care coordination components in a patient's electronic heath record.

Mortality and associated risk factors for older adults admitted to the emergency department: a hospital cohort

Background

Older emergency department patients are more vulnerable than younger patients, yet many risk factors that contribute to the mortality of older patients remain unclear and under investigation. This study endeavored to determine mortality and factors associated with mortality in patients over 60 years of age who were admitted to the emergency departments of two general hospitals in Mexico City.

Methods

This is a hospital cohort study involving adults over 60 years of age admitted to the emergency department and who are beneficiaries of the Mexican Institute of Social Security and residents of Mexico City.

All causes of mortality from the time of emergency department admission until a follow-up home visit after discharge were measured. Included risk factors were: socio-demographic, health-care related, mental and physical variables, and in-hospital care-related. Survival functions were estimated using Kaplan-Meier curves. Hazard ratios (HR) were derived from Cox regression models in a multivariate analysis.

Results

From the 1406 older adults who participated in this study, 306 (21.8%) did not survive. Independent mortality risk factors found in the last Cox model were age (HR = 1.02, 95% CI, 1.005–1.04; p = 0.01), length of stay in the ED (HR = 1.003, 95% CI = 0.99, 1.04; p = 0.006), geriatric care trained residents model in Hospital A (protective factor) (HR = 0.66, 95% CI = 0.46, 0.96; p = 0.031), and the FRAIL scale (HR of 1.34 95% CI, 1.02–1.76; p = 0.033).

Conclusions

Risk factors for mortality in patients treated at Mexican emergency departments are length of stay and variables related to frailty status.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

International Standard Randomised Controlled Trial Number ( ISRCTN12286422 ).