Multimorbidity and comorbidity in the Dutch population - data from general practices

Predicting unplanned admissions to hospital in older adults using routinely recorded general practice data: development and validation of a prediction model

BACKGROUND

Unplanned admissions to hospital represent a hazardous event for older people. Timely identification of high-risk individuals using a prediction tool may facilitate preventive interventions.

AIM

To develop and validate an easy-to-use prediction model for unplanned admissions to hospital in community-dwelling older adults using readily available data to allow rapid bedside assessment by GPs.

DESIGN AND SETTING

This was a retrospective study using the general practice electronic health records of 243 324 community-dwelling adults aged ≥65 years linked with national administrative data to predict unplanned admissions to hospital within 6 months.

METHOD

The dataset was geographically split into a development (n = 142 791/243 324, 58.7%) and validation (n = 100 533/243 324, 41.3%) sample to predict unplanned admissions to hospital within 6 months. The performance of three different models was evaluated with increasingly smaller selections of candidate predictors (optimal, readily available, and easy-to-use models). Logistic regression was used with backward selection for model development. The models were validated internally and externally. Predictive performance was assessed by area under the curve (AUC) and calibration plots.

RESULTS

In both samples, 7.6% (development cohort: n = 10 839/142 791, validation cohort: n = 7675/100 533) had ≥1 unplanned hospital admission within 6 months. The discriminative ability of the three models was comparable and remained stable after geographic validation. The easy-to-use model included age, sex, prior admissions to hospital, pulmonary emphysema, heart failure, and polypharmacy. Its discriminative ability after validation was AUC 0.72 (95% confidence interval = 0.71 to 0.72). Calibration plots showed good calibration.

CONCLUSION

The models showed satisfactory predictive ability. Reducing the number of predictors and geographic validation did not have an impact on predictive performance, demonstrating the robustness of the model. An easy-to-use tool has been developed in this study that may assist GPs in decision making and with targeted preventive interventions.

Valuing Outpatients' Perspective on Primary Health Care Services in Greece: A Cross-Sectional Survey on Satisfaction and Personal-Centered Care

INTRODUCTION

The aims of the study were to identify and analyze the determinants associated with outpatient satisfaction in Greek primary care. This is because there is a general consensus that primary care is the linchpin of effective person-centered care delivery.

METHODS

A cross-sectional survey was conducted with 1012 patients' exit interviews; sociodemographic variables were included in the questionnaire to obtain data on the satisfaction of primary care users with 20 public primary healthcare centers in Athens between June 2019 and April 2021. Statistical analysis was applied to 55 items and eight dimensions of patient satisfaction, namely, arrival and admission, waiting before the appointment, cleanliness of toilets, medical examination and behavior of physician, behavior of nursing staff, laboratories, departure, and contribution of the PHCs. Descriptive analyses and multiple linear regression were used to analyze the factors influencing patient satisfaction through coefficients (β) with 95% confidence intervals and associated tests of statistical significance.

RESULTS

Τwo-thirds (74.21%) of this survey's participants ranged from 45 to 74 years of age. More than half of the participants were women (62.15%). The most common reasons for visits were pathological (26.48%), followed by cardiological conditions (9.78%), orthopedics (9.49%), gynecologic conditions (8.70%), and ophthalmologic problems (7.31%). In the center of satisfaction with primary care was the medical care and the behavior of the physician (β = 0.427; p < 0.01), followed by the time during appointment (β = 0.390; p < 0.01). Dimensions like "accessibility and availability, 2.19/5"; "waiting times, 2.89/5"; "infrastructure of facilities (2.04/5) and cleanliness of them, (2/5)"; "laboratories, 2.99/5" and "bureaucracy in the departure, 2.29/5" were crucial for the trust and satisfaction of patients. Overall satisfaction was rated at a moderate level (2.62 ± 0.18) while person-centered care was rated as weak (2.49 ± 0.28).

CONCLUSIONS

Greece is recommended to increase the sensitivity of the use of the primary health care system by patients as a first contact, continuous, comprehensive, and effective patient- and family-focused care.

Multidisciplinary Collaboration in Hospitals via Patient- and Process-Oriented Units: A Longitudinal Study

Introduction

The complexity of healthcare is increasing, mainly due to the prevalence of multimorbidity in an ageing population. Complex care for patients with multimorbidity requires a multidisciplinary approach. Traditional physician-centered hospital structures do not facilitate the necessary multidisciplinary collaboration. European hospitals are implementing process-based hospital designs with patient- and process-oriented units to stimulate multidisciplinary collaboration. Patient-oriented units are formed based on shared patient groups and focus on care trajectories, while process-oriented units are formed based on having similar processes and focus on efficiency.

Purpose

This study has two aims. First, to study the effect of introduction of these units on multidisciplinary collaboration and perceived impact (efficiency, innovation, and effectiveness). Second, to study whether there are differences between patient- and process-oriented units.

Methods

A survey-based longitudinal evaluation study was conducted in 2020 and 2022 among physicians in a Dutch hospital to measure multidisciplinary collaboration (relational coordination) and perceived impact (efficiency, innovation, and effectiveness). In addition, open questions were used to enrich the data.

Results

Quantitative and qualitative data together suggest that physicians in patient-oriented units notice benefits from the redesign to multidisciplinary units, they perceive higher impact over time. Physicians in process-oriented units achieve a better relationship with the physicians in their unit over time, but they do not perceive impact as high as physicians in patient-oriented units.

Conclusion

A process-based design with patient- and process-oriented units is supportive of multidisciplinary collaboration and perceived impact, especially for physicians in patient-oriented units. Physicians in patient-oriented units are positive about the introduction of these units as they feel it contributes to better multidisciplinary patient care. As the results for physicians in process-oriented units may be less directly visible in terms of quality of care, they are less likely to see positive effects, even though their relationships are improving.

A dynamic probabilistic model of the onset and interaction of cardio-metabolic comorbidities on an ageing adult population

Comorbidity is widespread in the ageing population, implying multiple and complex medical needs for individuals and a public health burden. Determining risk factors and predicting comorbidity development can help identify at-risk subjects and design prevention strategies. Using socio-demographic and clinical data from approximately 11,000 subjects monitored over 11 years in the English Longitudinal Study of Ageing, we develop a dynamic Bayesian network (DBN) to model the onset and interaction of three cardio-metabolic comorbidities, namely type 2 diabetes (T2D), hypertension, and heart problems. The DBN allows us to identify risk factors for developing each morbidity, simulate ageing progression over time, and stratify the population based on the risk of outcome occurrence. By applying hierarchical agglomerative clustering to the simulated, dynamic risk of experiencing morbidities, we identified patients with similar risk patterns and the variables contributing to their discrimination. The network reveals a direct joint effect of biomarkers and lifestyle on outcomes over time, such as the impact of fasting glucose, HbA1c, and BMI on T2D development. Mediated cross-relationships between comorbidities also emerge, showcasing the interconnected nature of these health issues. The model presents good calibration and discrimination ability, particularly in predicting the onset of T2D (iAUC-ROC = 0.828, iAUC-PR = 0.294) and survival (iAUC-ROC = 0.827, iAUC-PR = 0.311). Stratification analysis unveils two distinct clusters for all comorbidities, effectively discriminated by variables like HbA1c for T2D and age at baseline for heart problems. The developed DBN constitutes an effective, highly-explainable predictive risk tool for simulating and stratifying the dynamic risk of developing cardio-metabolic comorbidities. Its use could help identify the effects of risk factors and develop health policies that prevent the occurrence of comorbidities.

Supporting professionals to implement integrated, person-centered care for people with chronic conditions: the TARGET pilot study

OBJECTIVE

The TARGET program for integrated, person-centered care for people with chronic conditions offers primary care (PC) professionals a set of tools and trainings to actively engage in population segmentation and person-centered needs assessments (PCNAs). A pilot study was conducted to gain insight into the program's feasibility and acceptability, and identify preconditions for successful implementation.

DESIGN AND SETTING

Seven Dutch PC practices participated in a half-year pilot study starting in August 2020. We performed a review of the population segmentation tool, observed four training sessions and 15 PCNAs, and interviewed 15 professionals and 12 patients.

RESULTS

Regarding feasibility and acceptability, we found that the tools and trainings provided professionals with skills to use the segmentation tool and take a more coaching role in the well-appreciated PCNAs. Concerning implementation preconditions, we found that team commitment and network connections need improvement, although work pleasure increased and professionals generally wanted the program to continue.

CONCLUSIONS

While the content of the TARGET program is supported by its users, the implementation process, for instance team commitment to the program, needs more attention in future upscaling efforts.

Periodontitis is associated with multimorbidity in a large dental school population

AIM

To investigate whether and which diseases co-occur with periodontitis (PD) to assess the prevalence of comorbidities and multimorbidity and to identify patterns and profiles of comorbidity and multimorbidity and the influence of demographic and lifestyle factors to identify distinct groups of multimorbid patients.

MATERIALS AND METHODS

A database from the Academic Centre of Dentistry Amsterdam (ACTA) with 37,801 adult individuals containing information about demographic (age, sex, socio-economic position [SEP]) and lifestyle factors (smoking, alcohol use and addictive substance use) and PD and systemic diseases was constructed. PD assessment was based on clinical information by the use of claim codes and systemic diseases data were derived from self-reported medical history. For analyses, univariable and multivariable (adjusted for age, sex, SEP, smoking, alcohol use and addictive substance use) logistic regression analyses and cluster analysis were used.

RESULTS

Individuals with PD more often had one or multiple diseases. The adjusted odds ratio (OR) for PD patients having up to four systemic diseases ranged from 1.46 to 1.20. Co-occurrence of PD with several systemic diseases and a higher prevalence of multimorbidity was found (adjusted OR comorbidity = 1.36; 95% confidence interval (CI): 1.30-1.43; multimorbidity = 1.18; 95% CI: 1.11-1.25). Four clusters existed: cluster 1 was defined as a periodontal and systemically healthy group and cluster 4 as burdened with PD but not containing any systemic diseases. Individuals in cluster 1 were of the lowest age (44.9 [SD: 15.5]) and had the lowest prevalence of the lifestyle factors of smoking (13.6%) and alcohol use (3.9%). Clusters 2 and 3 contained both PD and had several systemic diseases but were different from each other. Cluster 2 contained 34.5% of PD individuals and had mainly respiratory tract, immune system and digestive system diseases. Cluster 3 contained 45.9% of PD individuals and had mainly cardiometabolic diseases. Cluster 2 had the highest prevalence of females (63.1%) and the highest prevalence of smokers (23.8%) and addictive substance users (8.9%). Cluster 3 included individuals of the highest age (63.5 [SD: 11.9]), and had highest prevalence of alcohol users (17.7%) and lowest prevalence of addictive substance users (3.8%).

CONCLUSIONS

This study shows that individuals with PD are more often burdened with comorbidity and multimorbidity. Presence of distinct clusters suggests overlap in pathophysiology between certain types of PD and specific systemic diseases. Therefore, PD can be considered as part of multimorbidity, as one of the systemic diseases co-occurring in certain groups of individuals.

Impact of health-related behavioral factors on participation in a cervical cancer screening program: the lifelines population-based cohort

BACKGROUND

Regular participation in cervical cancer screening is critical to reducing mortality. Although certain sociodemographic factors are known to be associated with one-time participation in screening, little is known about other factors that could be related to regular participation. Therefore, this study evaluated the association between health-related behavioral factors and regular participation in cervical cancer screening.

METHODS

The Lifelines population-based cohort was linked to data for cervical cancer screening from the Dutch Nationwide Pathology Databank. We included women eligible for all four screening rounds between 2000 and 2019, classifying them as regular (4 attendances), irregular (1-3 attendances), and never participants. Multinomial logistic regression was performed to evaluate the association between behavioral factors and participation regularity, with adjustment made for sociodemographic factors.

RESULTS

Of the 48,325 included women, 55.9%, 35.1%, and 9% were regular, irregular, and never screening participants. After adjustment for sociodemographic factors, the likelihood of irregular or never screening participation was increased by smoking, obesity, marginal or inadequate sleep duration, alcohol consumption and low physical activity, while it was decreased by hormonal contraception use.

CONCLUSION

An association exists between unhealthy behavioral factors and never or irregular participation in cervical cancer screening.

Clinical leaders crossing boundaries: A study on the role of clinical leadership in crossing boundaries between specialties

BACKGROUND

Due to the growing number of complex (multimorbid) patients, integrating and coordinating care across medical specialties around patient needs is an urgent theme in current health care. Clinical leadership plays an important role in stimulating coordination both within and between specialty groups, which results in better outcomes in terms of job satisfaction and quality of care.

PURPOSE

In this light, this study aims to understand the relation between physicians' clinical leadership and outcomes, focusing on the sequential mediation of relationships and coordination with physicians within their own medical specialty group and from other specialties.

METHODOLOGY

A cross-sectional self-administered survey among physicians in a Dutch hospital (n = 107) was conducted to measure clinical leadership, relational coordination at two levels (medical specialty group and between different specialties), quality of care, and job satisfaction.

RESULTS

Clinical leadership was related to better quality of care through more relational coordination within the medical specialty group. Clinical leadership was related to more job satisfaction through more relational coordination within the medical specialty group, through more relational coordination between specialties, and sequentially through both kinds of relational coordination.

CONCLUSION

Physicians who act as clinical leaders are important for crossing specialist boundaries and increasing care outcomes.

PRACTICAL IMPLICATIONS

To improve multidisciplinary collaboration, managers should encourage clinical leadership and pay attention to the strong relationships between physicians from the same specialty.

Meal Frequency and Multi-Morbidity in a Cypriot Population: A Cross-Sectional Study

Data regarding the effect of specific dietary behaviors, such as meal frequency, on multi-morbidity are scarce. Therefore, the objective of this study was to examine the effect of meal frequency on multi-morbidity in a Cypriot population. A representative sample of 1255 adults >18 years old was surveyed during 2022-2023. Data regarding sociodemographic characteristics, multi-morbidity, and meal frequency consumption were collected through validated questionnaires. Diseases were listed according to the International Classification of Diseases, 10th Revision [ICD-10]. Statistical analysis was conducted using SPSS Statistics v.19.0. Responders who consumed more than three meals and snacks daily had a higher probability of multi-morbidity [OR: 1.505 [95% CI: 1.505-2.069]] compared with those who consumed three or fewer meals and snacks daily. The relation was not statistically significant after adjusting for age and gender and for socioeconomic characteristics. Furthermore, participants who consumed more than three snacks per day had a 1.776 [AOR: 1.616 [95% CI: 1.054-2.476]] higher risk of having multi-morbidity compared with participants who did not consume any snack or consumed one snack per day. The findings suggest that people with multi-morbidity have a higher risk when consuming three or more snacks per day regardless of age, gender, and socioeconomic characteristics.

Identification of status quo and association rules for chronic comorbidity among Chinese middle-aged and older adults rural residents

Background

Chronic comorbidity has become a major challenge in chronic disease prevention and control. This issue is particularly pronounced in rural areas of developing countries, where the prevalence of chronic disease comorbidity is high, especially among middle-aged and older adults populations. However, the health status of middle-aged and older adults individuals in rural areas of China has received inadequate attention. Therefore, it is crucial to investigate the correlation among chronic diseases to establish a reference basis for adjusting health policies aimed at promoting the prevention and management of chronic diseases among middle-aged and older adults individuals.

Methods

This study selected 2,262 middle-aged and older adults residents aged 50 years or older in Shangang Village, Jiangsu Province, China, as the study population. To analyze the chronic comorbidity of middle-aged and older adults residents with different characteristics, we used the χ² test with SPSS statistical software. Data analysis was conducted using the Apriori algorithm of Python software, set to mine the strong association rules of positive correlation between chronic disease comorbidities of middle-aged and older adults residents.

Results

The prevalence of chronic comorbidity was 56.6%. The chronic disease comorbidity group with the highest prevalence rate was the lumbar osteopenia + hypertension group. There were significant differences in the prevalence of chronic disease comorbidity among middle-aged and older adults residents in terms of gender, BMI, and chronic disease management. The Apriori algorithm was used to screen 15 association rules for the whole population, 11 for genders, and 15 for age groups. According to the order of support, the most common association rules of comorbidity of three chronic diseases were: {lumbar osteopenia} → {hypertension} (support: 29.22%, confidence: 58.44%), {dyslipidemia} → {hypertension} (support: 19.14%, confidence: 65.91%) and {fatty liver} → {hypertension} (support: 17.82%, confidence: 64.17%).

Conclusion

The prevalence of chronic comorbidity among middle-aged and older adults rural residents in China is relatively high. We identified many association rules among chronic diseases, dyslipidemia is mostly the antecedent, and hypertension is primarily the result. In particular, the majority of comorbidity aggregation patterns consisted of hypertension and dyslipidemia. By implementing scientifically-proven prevention and control strategies, the development of healthy aging can be promoted.

Long-term Effects of a Collaborative Care Model on Metabolic Outcomes and Depressive Symptoms: 36-Month Outcomes from the INDEPENDENT Intervention

BACKGROUND

Collaborative care (CC) is a multicomponent team-based approach to providing mental health care with systematic integration into outpatient medical settings. The 12-month INDEPENDENT CC intervention improved joint disease control measures in patients with both depression and diabetes at 12 and 24 months following randomization.

OBJECTIVE

This study investigated the durability of intervention effects on patient outcomes at 36 months following randomization.

PARTICIPANTS

Adult patients with poorly controlled T2D and depression in India randomized to CC or usual care.

DESIGN

Post hoc analyses of between-group differences in patient outcomes at 36 months post-randomization (N = 331) and maintenance of outcomes from 12 to 36 months (N = 314).

MAIN MEASURES

We evaluated combined risk factor improvement since baseline, defined as ≥ 50.0% reduction in Symptom Checklist Depression Scale (SCL-20) scores along with reduction of at least 0.5 percentage point hemoglobin A1C, 5 mmHg systolic blood pressure, or 10 mg/dL low-density lipoprotein cholesterol. Improvements in single risk factors were also examined.

KEY RESULTS

There were no between-group differences in improvements since baseline in multiple or single risk factors at 36 months. Patients in the CC group with improved outcomes at 12 months were more likely to maintain a ≥ 50.0% reduction since baseline in SCL-20 scores (CC [54.9%] vs. UC [40.9%]; RR: 1.27 [95% CI: 1.04, 1.56]) and 0.5 percentage point reduction since baseline in hemoglobin A1C (CC [31.9%] vs. UC [19.5%]; RR: 1.64 [95% CI: 1.11, 2.41]) at 36 months.

CONCLUSIONS

While improvements since baseline in patient outcomes did not differ between the collaborative care and usual care groups at 36 months, patients who received CC were more likely to maintain improvements in depressive symptoms and glucose levels at 36 months if they had achieved these improvements at the end of active intervention.

TRIAL REGISTRATION NUMBER

NCT02022111.

Are social determinants of health associated with the development of early complications among young adults with type 2 diabetes? A population based study using linked databases

AIMS

To quantify the impact of social determinants of health (SDOH) on top of medical determinants on the development of diabetes-related complications in young adults with type 2 diabetes.

METHODS

In this observational population-based study, SDOH (income and origin) were linked to routine primary care data. Young adults (18-45 years) with incident type 2 diabetes between 2007 and 2013 were included. The main outcome, the development of the first micro- or macrovascular complication, was analyzed by multivariate Cox regression. Medical determinants included antidiabetic treatment, HbA1c in the year after diagnosis, body mass index, comorbidity and smoking.

RESULTS

Of 761 young adults (median age: 39 years (IQR 33-42), men: 49%, Western origin: 36%, low income: 48%), 154 developed at least one complication (median follow-up 99 months (IQR 73-123)). Young men of non-Western origin were more likely to develop a complication (HR 1.98 (1.19-3.30)), as were young adults with HbA1c > 7% (>53 mmol/mol) (HR: 1.72 95% CI: 1.15-2.57). No associations were found with income. Being women was protective.

CONCLUSION

In this multi-ethnic population, non-Western origin was associated with the development of complications, but only in men. Low income was not associated with developing complications. The importance of adequate HbA1c regulation was re-emphasized by this study.

The Effect and Cost-Effectiveness of Offering a Combined Lifestyle Intervention for the Prevention of Cardiovascular Disease in Primary Care: Results of the Healthy Heart Stepped-Wedge Trial

OBJECTIVE

To evaluate the effectiveness and cost-effectiveness of offering the combined lifestyle programme "Healthy Heart", addressing overweight, diet, physical activity, smoking and alcohol, to improve lifestyle behaviour and reduce cardiovascular risk.

DESIGN

A practice-based non-randomised stepped-wedge cluster trial with two-year follow-up. Outcomes were obtained via questionnaires and routine care data. A cost-utility analysis was performed. During the intervention period, "Healthy Heart" was offered during regular cardiovascular risk management consultations in primary care in The Hague, The Netherlands. The period prior to the intervention period served as the control period.

RESULTS

In total, 511 participants (control) and 276 (intervention) with a high cardiovascular risk were included (overall mean ± SD age 65.0 ± 9.6; women: 56%). During the intervention period, 40 persons (15%) participated in the Healthy Heart programme. Adjusted outcomes did not differ between the control and intervention period after 3-6 months and 12-24 months. Intervention versus control (95% CI) 3-6 months: weight: β -0.5 (-1.08-0.05); SBP β 0.15 (-2.70-2.99); LDL-cholesterol β 0.07 (-0.22-0.35); HDL-cholesterol β -0.03 (-0.10-0.05); physical activity β 38 (-97-171); diet β 0.95 (-0.93-2.83); alcohol OR 0.81 (0.44-1.49); quit smoking OR 2.54 (0.45-14.24). Results were similar for 12-24 months. Mean QALYs and mean costs of cardiovascular care were comparable over the full study period (mean difference (95% CI) QALYs: -0.10 (-0.20; 0.002); costs: EUR 106 (-80; 293)).

CONCLUSIONS

For both the shorter (3-6 months) and longer term (12-24 months), offering the Healthy Heart programme to high-cardiovascular-risk patients did not improve their lifestyle behaviour nor cardiovascular risk and was not cost-effective on a population level.

Association of disability level with polypharmacy and potentially inappropriate medication in community dwelling older people

AIMS

To investigate the influence of disability severity level on polypharmacy and the prescription of potentially inappropriate medication (PIM) using health insurance and long-term care (LTC) insurance claim data.

METHODS

Data were obtained from a health-care insurance and long-term care insurance claims database of citizens of Kure city, Japan, in April 2017. Data including age, sex, and drug profile were obtained, and the level of LTC needs was used to measure disability level. Factors associated with polypharmacy (≥5 prescribed drugs) and PIM prescription (≥1 PIM) defined by STOPP-J were analyzed statistically.

RESULTS

Among 67,169 people aged ≥65 (mean age 77.2 ± 7.9, male 40.7%), the frequency of polypharmacy increased with age until 85-89 (male 58.3%, female 57.6%) in both genders, and polypharmacy was most prevalent in those at the mildest LTC level (support level: male 68.9%, female 73.7%). PIM prescriptions was also frequent in those with LTC needs. On multiple logistic regression analysis, polypharmacy was significantly associated with older age and LTC needs, and PIM prescription was associated with older age and higher LTC level, suggesting that there is a large difference in prescription according to the person's age and disability level.

CONCLUSION

Polypharmacy was prevalent especially in older persons which peaked at the age of 85-89 or at mild disability level, and PIM prescription was prevalent in those with older age and higher care levels. When optimizing polypharmacy or PIM prescription in older patients, healthcare providers should focus on not only age but also disability level.

Self-reported psychological symptoms and severe stress events, but not patients' gender, affect illness representation and medical advice by lay-referral network advisors

People who experience symptoms tend to discuss their ailments with other individuals who create their own illness representations, acting as intuitive physicians. We conducted two experimental studies to examine lay-referral network advisors' (i.e., acquaintances) representation of illness etiology and their recommendation to undergo health screenings for a man or woman with physical (vs. both physical and psychological) symptoms and a severe stressful (vs. no stressful) period in life. The presence of psychological and physical symptoms (Studies 1 and 2) and severe stressful life events (Study 2) affects lay-referral network advisors' disease representation. These factors cause participants to attribute symptoms etiology to psychological rather than organic factors and recommend more psychological screenings rather than physical ones. The simultaneous presence of psychological and physical symptoms and severe stressful events increases the likelihood of attributing the illness etiology to psychological factors, which increases participants' willingness to recommend psychological screenings. Study variables were unaffected by patient gender. The main findings, limitations, and future directions are discussed.

Designing the learning of intraprofessional collaboration among medical residents

BACKGROUND

To preserve quality and continuity of care, collaboration between primary-care and secondary-care physicians is becoming increasingly important. Therefore, learning intraprofessional collaboration (intraPC) requires explicit attention during postgraduate training. Hospital placements provide opportunities for intraPC learning, but these opportunities require interventions to support and enhance such learning. Design-Principles guide the design and development of educational activities when theory-driven Design-Principles are tailored into context-sensitive Design-Principles. The aim of this study was to develop and substantiate a set of theory-driven and context-sensitive Design-Principles for intraPC learning during hospital placements.

METHODS

Based on our earlier research, we formulated nine theory-driven Design-Principles. To enrich, refine and consolidate these principles, three focus group sessions with stakeholders were conducted using a Modified Nominal Group Technique. Next, two work conferences were conducted to test the feasibility and applicability of the Design-Principles for developing intraPC educational activities and to sharpen the principles into a final set of Design-Principles.

RESULTS

The theoretical Design-Principles were discussed and modified iteratively. Two new Design-Principles were added during focus group 1, and one more Design-Principle was added during focus group 2. The Design-Principles were categorised into three clusters: (i) Culture: building collaborative relations in a psychologically safe context where patterns or feelings of power dynamics between primary and secondary care physicians can be discussed; (ii) Connecting Contexts: making residents and supervisors mutually understand each other's work contexts and activities; and (iii) Making the Implicit Explicit: having supervising teams act as role models demonstrating intraPC and continuously pursuing improvement in intraPC to make intraPC explicit. Participants were unanimous in their view that the Design-Principles in the Culture cluster were prerequisites to facilitate intraPC learning.

CONCLUSION

This study led to the development of 12 theory-driven and context-sensitive Design-Principles that may guide the design of educational activities to support intraPC learning during hospital placements.

Sex Differences in Comorbidity Combinations in the Swedish Population

High comorbidity rates, especially mental–physical comorbidity, constitute an increasing health care burden, with women and men being differentially affected. To gain an overview of comorbidity rates stratified by sex across a range of different conditions, this study examines comorbidity patterns within and between cardiovascular, pulmonary, skin, endocrine, digestive, urogenital, musculoskeletal, neurological diseases, and psychiatric conditions. Self-report data from the LifeGene cohort of 31,825 participants from the general Swedish population (62.5% female, 18–84 years) were analyzed. Pairwise comorbidity rates of 54 self-reported conditions in women and men and adjusted odds ratios (ORs) for their comparison were calculated. Overall, the rate of pairwise disease combinations with significant comorbidity was higher in women than men (14.36% vs. 9.40%). Among psychiatric conditions, this rate was considerably high, with 41.76% in women and 39.01% in men. The highest percentages of elevated mental–physical comorbidity in women were found for musculoskeletal diseases (21.43%), digestive diseases (20.71%), and skin diseases (13.39%); in men, for musculoskeletal diseases (14.29%), neurological diseases (11.22%), and digestive diseases (10%). Implications include the need for integrating mental and physical health care services and a shift from a disease-centered to an individualized, patient-centered focus in clinical care.

Multimorbidity as assessed by reporting of multiple causes of death: variations by period, sociodemographic characteristics and place of death among older decedents in England and Wales, 2001-2017

BACKGROUND

Multimorbidity is common at older ages and is associated with disability, frailty and poor quality of life. Research using clinical databases and surveys has shown associations between multimorbidity and indicators of social disadvantage. Use of multiple coded death registration data has been proposed as an additional source which may also provide insights into quality of death certification.

METHODS

We investigate trends in reporting multiple causes of death during 2001-2017 among decedents aged 65 years and over included in a census-based sample of 1% of the England and Wales population (Office for National Statistics Longitudinal Study). Using Poisson regression analysis, we analyse variations in number of mentions of causes of death recorded by time period, place of death, age, sex and marital status at death and indicators of health status and individual and area socioeconomic disadvantage reported at the census prior to death.

RESULTS

Number of mentions of causes recorded at death registration increased 2001-2017, increased with age, peaking among decedents aged 85-9 years, and was positively associated with indicators of prior disadvantage and poor health, although effects were small. Number of mentions was highest for hospital decedents and similar for those dying in care homes or their own homes.

CONCLUSION

Socioeconomic disadvantage, prior poor health, dying in hospital and older age-although not extreme old age-are associated with dying with more recorded conditions. Results may reflect both differences in multimorbidity at death and variations in quality of medical certification of death. Quality of death certification for decedents in care homes needs further investigation.

Achieving diabetes treatment targets in people with registered mental illness is similar or improved compared with those without: Analyses of linked observational datasets

AIMS

To determine the association between registered mental illness and type 2 diabetes mellitus treatment targets, while taking into account the effects of health expenditure and social determinants of health.

METHODS

This observational cross-sectional study was based on routine primary care data, linked to socio-economic and medical claims data. The main outcomes, analysed by multivariate logistic regression, were achieving primary care guideline treatment targets for HbA1c , systolic blood pressure (SBP) and LDL-cholesterol in 2017. We examined the association with diagnosed mental illness registered by the general practitioner (GP) or treated via specialist' mental healthcare between 2016 and 2018, adjusting for, medication use, body mass index, co-morbidity, smoking, and additionally examining effect-modification of healthcare expenditures, migration status, income and demographics.

RESULTS

Overall (N = 2862), 64.0% of participants achieved their treatment targets for HbA1c , 65.1% for SBP and 53.0% for LDL-cholesterol. Adjusted for migrant background, income and care expenditures, individuals <65 years of age with mental illness achieved their HbA1c treatment target more often than those without (OR (95% CI)): treatment by GP: 1.46 (1.01, 2.11), specialist care: 1.61 (1.11, 2.34), as did men with mental illness for SBP: GP OR 1.61 (1.09, 2.40), specialist care OR 1.59 (1.09, 2.45). LDL-cholesterol target was not associated with mental illness. A migrant background or low income lowered the likelihood of reaching HbA1c targets.

CONCLUSIONS

People with registered mental illness appear comparable or better able to achieve diabetes treatment targets than those without. Achieving HbA1c targets is influenced by social disadvantage.

Long-Term High Dietary Diversity Maintains Good Physical Function in Chinese Elderly: A Cohort Study Based on CLHLS from 2011 to 2018

(1) Objective: This study aimed to explore the correlation between dietary factors and physical function in Chinese elderly. (2) Methods: A cohort study was conducted on the association of long-term dietary intake status with physical function in older people based on the Chinese Longitudinal Healthy Longevity Survey (CLHLS) from 2011 to 2018. The physical function of the subjects was judged according to the scores of basic activities of daily living (BADL) and instrumental activities of daily living (IADL). The dietary diversity score was established according to the intake frequency of the food groups, and the dietary pattern score was obtained by factor analysis. The associations between dietary factors and functional impairment was investigated by logistic regressions. (3) Results: A total of 2282 subjects were included in our cohort study, 458 and 1439 of whom had BADL limitation and IADL limitation, respectively. The risk of functional impairment decreased in the consistent high dietary diversity groups compared with the consistent low dietary diversity group (p < 0.05). The fruit-egg-milk pattern, vegetable-meat-fish pattern, and condiment and tea pattern reduced the risk of functional impairment (p < 0.05). (4) Conclusions: Long-term maintenance of high dietary diversity and increasing total dietary intake can help maintain good physical function of Chinese elderly.

Differences in treatment and survival of older patients with operable breast cancer between the United Kingdom and the Netherlands – A comparison of two national prospective longitudinal multi-centre cohort studies

Background

Previous studies have shown that survival outcomes for older patients with breast cancer vary substantially across Europe, with worse survival reported in the United Kingdom. It has been hypothesised that these differences in survival outcomes could be related to treatment variation.

Objectives

We aimed to compare patient and tumour characteristics, treatment selection and survival outcomes between two large prospective cohorts of older patients with operable breast cancer from the United Kingdom (UK) and The Netherlands.

Methods

Women diagnosed with operable breast cancer aged ≥70 years were included. A baseline comprehensive geriatric assessment was performed in both cohorts, with data collected on age, comorbidities, cognition, nutritional and functional status. Baseline tumour characteristics and treatment type were collected. Univariable and multivariable Cox regression models were used to compare overall survival between the cohorts.

Results

3262 patients from the UK Age Gap cohort and 618 patients from the Dutch Climb cohort were included, with median ages of 77.0 (IQR: 72.0–81.0) and 75.0 (IQR: 72.0–81.0) years, respectively. The cohorts were generally comparable, with slight differences in rates of comorbidity and frailty. Median follow-up for overall survival was 4.1 years (IQR 2.9–5.4) in Age Gap and 4.3 years (IQR 2.9–5.5) in Climb. In Age Gap, both the rates of primary endocrine therapy and adjuvant hormonal therapy after surgery were approximately twice those in Climb (16.6% versus 7.3%, p < 0.001 for primary endocrine therapy, and 62.2% versus 38.8%, p < 0.001 for adjuvant hormonal therapy). There was no evidence of a difference in overall survival between the cohorts (adjusted HR 0.94, 95% CI 0.74–1.17, p = 0.568).

Conclusions

In contrast to previous studies, this comparison of two large national prospective longitudinal multi-centre cohort studies demonstrated comparable survival outcomes between older patients with breast cancer treated in the UK and The Netherlands, despite differences in treatment allocation.

•

No survival difference between UK and Netherlands for older breast cancer patients.

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Similar patient and tumour characteristics seen in both cohorts.

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Higher rates of mastectomy for older breast cancer patients in Netherlands.

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Higher rates of adjuvant therapies for older breast cancer patients in UK.

Simulating lifestyle and medical interventions to prevent type-2 diabetes: an economic evaluation for Belgium

By 2040, over half a billion people globally are expected to have diabetes. This disease implies a loss in life quality and comes with a significant financial impact. To avoid prevalence increases in the main category of diabetes-type-2 diabetes (T-2D)-, preventive action among high-risk groups is necessary. Lifestyle and medical interventions with metformin among prediabetic individuals show strong potential to decrease or delay T-2D. The aim of this paper is to evaluate the cost-effectiveness and budget impact of a nation-wide implementation of these interventions, between 2020 and 2040, in Belgium. This is done through a dynamic, non-homogeneous, semi-Markov model which simulates prevalence and costs of a type of prediabetes (impaired glucose tolerance or IGT) and T-2D in Belgium. High-risk individuals are first screened; individuals with IGT then enroll in a lifestyle or metformin program. Compared to no intervention, both programs are very cost effective from the perspective of the health care system and cost-saving from a broader societal perspective. Both interventions require an initial, affordable government investment and later yield government savings. The lifestyle program is a cost-effective alternative to the metformin intervention and may yield additional benefits through, for example, improvements in mental health.

Sociodemographic and behavioral influences on multimorbidity among adult residents of northeastern China

Background

Multimorbidity is defined as two or more chronic health conditions existing in an individual simultaneously. Multimorbidity has been associated with poor conditions, such as higher health care costs and the poor quality of life. Thus, identifying the risk factors of the multimorbidity is required for multimorbidity prevention.

Methods

This study was based on the Comprehensive Demonstration Research Project of Major Chronic Noncommunicable Disease Prevention and Control Technology in Northeast China initiated by China Medical University. The investigation was a cross-sectional study under a multistage stratified cluster random sampling design. Associations between multimorbidity and sociodemographic and behavioral factors in adult residents were investigated using univariate analysis and multivariate logistic regression analysis.

Results

A total of 6706 participants were enrolled in this investigation, and the prevalence of multimorbidity was 21.2% among the adult residents of northeastern China. There existed differences of association between age and multimorbidity risks (65–69 years old: OR = 3.53, 95%CI: 2.04–6.12; 70–74 years old: OR = 5.26, 95%CI: 3.02–9.17). Participants who are overweight had significantly high multimorbidity risk (OR = 2.76, 95%CI: 1.50–5.24). Family history of hypertension and family history of diabetes were significantly associated with high multimorbidity risk (family history of hypertension: OR = 2.34, 95%CI: 1.96–2.79; family history of diabetes: OR = 1.77, 95%CI: 1.38–2.26). Compared with the frequency of fatigue (< 1 time/week or 1–2 times/week), that (≥3 times/week) was associated with high multimorbidity risk (OR = 1.39, 95%CI: 1.07–1.81). For fresh fruit consumption, compared with eating fruits regularly, eating rarely had a higher risk of multimorbidity (OR = 2.33, 95%CI: 1.90–2.85).

Conclusions

Sociodemographic indices (age, BMI, family history of hypertension, and family history of diabetes) and behavioral indices (fatigue status and fresh fruit consumption) increase the risks of multimorbidity. This study provides a necessary route to prevent and control multimorbidity in northeast China.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12722-y.

Caminho na rede formal de cuidado em saúde de pacientes pós-alta hospitalar segundo multimorbidade

Introdução: A gestão de informações associadas à multimorbidade na atenção hospitalar é relevante para o planejamento de estratégias de prevenção de agravos à saúde em pacientes de maior risco, a fim de oportunizar a organização de sistemas de saúde de modo eficiente. Objetivo: O presente trabalho objetivoudelinear o caminho formal percorrido por pacientes com e sem multimorbidade, considerando o uso da rede pública de saúde após a internação hospitalar. Materiais e métodos: Realizou-se um estudo quantitativo, transversal, descritivo, utilizando dados primários de 445 pacientes internados em um hospital universitário, no ano de 2018. Os dados foram coletados através de análise do prontuário médico e entrevista telefônica. Os resultados foram analisados por meio de frequência absoluta e relativa. Resultados: Desenvolveu-se um fluxograma, representando os pontos da rede de saúde utilizados pelo paciente após a alta hospitalar, segundo multimorbidade. Verificou-se uma alta prevalência de encaminhamento (com multimorbidade (CM) 93,52%; sem multimorbidade (SM) 97,71%) e comparecimento na atenção secundária à saúde (CM 86,15%; SM 89,63%), um baixo encaminhamento (CM 42,45%; SM 36,27%) e comparecimento na atenção primária à saúde (CM 61,29%; SM 64,81%), e considerando os 3 níveis de atenção juntos, houve um baixo comparecimento (CM 17,98%; SM 21,89%) para ambos os grupos investigados. Discussão: Entende-se que a semelhança de comparecimento em todos os pontos da rede por ambos os grupos é um problema, por tratar de forma igual populações desiguais e consequentemente com necessidades diversas. Conclusões: Sinaliza-se a importância de maior incentivo ao acompanhamento de pacientes com multimorbidade na rede primária de saúde, especialmente no período de pós-alta hospitalar, e a necessidade de fortalecimento da Rede de Atenção à Saúde.

Development and internal validation of a risk prediction model for falls among older people using primary care electronic health records

Background

Currently used prediction tools have limited ability to identify community-dwelling older people at high risk for falls. Prediction models utilizing electronic health records (EHRs) provide opportunities but up to now showed limited clinical value as risk stratification tool, because of among others the underestimation of falls prevalence. The aim of this study was to develop a fall prediction model for community-dwelling older people using a combination of structured data and free text of primary care EHRs and to internally validate its predictive performance.

Methods

We used EHR data of individuals aged 65 or older. Age, sex, history of falls, medications, and medical conditions were included as potential predictors. Falls were ascertained from the free text. We employed the Bootstrap-enhanced penalized logistic regression with the least absolute shrinkage and selection operator to develop the prediction model. We used 10-fold cross-validation to internally validate the prediction strategy. Model performance was assessed in terms of discrimination and calibration.

Results

Data of 36 470 eligible participants were extracted from the data set. The number of participants who fell at least once was 4 778 (13.1%). The final prediction model included age, sex, history of falls, 2 medications, and 5 medical conditions. The model had a median area under the receiver operating curve of 0.705 (interquartile range 0.700–0.714).

Conclusions

Our prediction model to identify older people at high risk for falls achieved fair discrimination and had reasonable calibration. It can be applied in clinical practice as it relies on routinely collected variables and does not require mobility assessment tests.

The impact of comorbidities and their stacking on short- and long-term prognosis of patients over 50 with community-acquired pneumonia

BACKGROUND

The prognosis of patients hospitalized with community-acquired pneumonia (CAP) with regards to intensive care unit (ICU) admission, short- and long-term mortality is correlated with patient's comorbidities. For patients hospitalized for CAP, including P-CAP, we assessed the prognostic impact of comorbidities known as at-risk (AR) or high-risk (HR) of pneumococcal CAP (P-CAP), and of the number of combined comorbidities.

METHODS

Data on hospitalizations for CAP among the French 50+ population were extracted from the 2014 French Information Systems Medicalization Program (PMSI), an exhaustive national hospital discharge database maintained by the French Technical Agency of Information on Hospitalization (ATIH). Their admission diagnosis, comorbidities (nature, risk type and number), other characteristics, and their subsequent hospital stays within the year following their hospitalization for CAP were analyzed. Logistic regression models were used to assess the associations between ICU transfer, short- and 1-year in-hospital mortality and all covariates.

RESULTS

From 182,858 patients, 149,555 patients aged ≥ 50 years (nonagenarians 17.8%) were hospitalized for CAP in 2014, including 8270 with P-CAP. Overall, 33.8% and 90.5% had ≥ 1 HR and ≥ 1 AR comorbidity, respectively. Cardiac diseases were the most frequent AR comorbidity (all CAP: 77.4%). Transfer in ICU occurred for 5.4% of CAP patients and 19.4% for P-CAP. Short-term and 1-year in-hospital mortality rates were 10.9% and 23% of CAP patients, respectively, significantly lower for P-CAP patients: 9.2% and 19.8% (HR 0.88 [95% CI 0.84-0.93], p < .0001). Both terms of mortality increased mostly with age, and with the number of comorbidities and combination of AR and HR comorbidities, in addition of specific comorbidities.

CONCLUSIONS

Not only specific comorbidities, but also the number of combined comorbidities and the combination of AR and HR comorbidities may impact the outcome of hospitalized CAP and P-CAP patients.

Cognitive decline before and after a first-ever stroke in Africans

OBJECTIVES

There is a knowledge gap on the impact of pre-existing cognitive decline on poststroke decline in indigenous Africans. We describe the trajectories of domain-specific cognitive and activities of daily life (ADL) functioning across the first year of stroke in Nigerians with pre-existing cognitive decline.

MATERIALS AND METHODS

Prospective observational study. Prestroke cognitive decline was ascertained retrospectively using the 16-item Informant Questionnaire for Cognitive Decline in the Elderly (IQCODE). Assessments for global cognition, learning, memory, executive and ADL functioning were conducted at 3 time points using the Mini-Mental state examination (MMSE), 10-words list learning and delayed recall test (10 WDRT), Animal naming test and Barthel index, respectively.

RESULTS

Among 150 stroke survivors, prestroke cognitive decline was found in 25 (16.7%, 95% C.I = 11.5%-23.6%). In linear regression analyses adjusting for the effect of age, education, stroke severity and comorbid diabetes mellitus, prestroke cognitive decline predicted poor memory scores at one year [Adjusted standardized mean difference (SMD) = -0.6, 95% C.I = -1.1, -0.1, p = 0.016)]. The association of prestroke cognitive decline with poststroke poor memory was substantially mediated by age (SMD = -0.9, 95% C.I = -1.4, -0.4, p < 0.001).

CONCLUSION

Pre-existing cognitive decline in this sample was associated with an age-mediated poor memory function at one-year poststroke. Early institution of targeted cognitive rehabilitation in stroke survivors with pre-existing cognitive decline may reduce the neurocognitive burden of stroke in Black Africans.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Multimorbidity in Canadians living in the community: Results from the Canadian Longitudinal Study of Aging

OBJECTIVE

To determine the mean number of chronic diseases in Canadians aged 45 to 85 years who are living in the community, and to characterize the association of multimorbidity with age, sex, and social position.

DESIGN

An analysis of data from the Canadian Longitudinal Study on Aging. The number of self-reported chronic diseases was summed, and then the mean number of chronic health problems was standardized to the 2011 Canadian population. Analyses were conducted stratified on sex, age, individual income, household income, and education level.

SETTING

Canada.

PARTICIPANTS

A total of 21 241 community-living Canadians aged 45 to 85 years.

MAIN OUTCOME MEASURES

Overall, 31 chronic diseases (self-reported from a list) were considered, as were risk factors that were not mental health conditions or acute in nature. Age, sex, education, and household and individual incomes were also self-reported.

RESULTS

Multimorbidity was common, and the mean number of chronic illnesses was 3.1. Women had a higher number of chronic illnesses than men. Those with lower income and less education had more chronic conditions. The number of chronic conditions was strongly associated with age. The mean number of conditions was 2.1 in those aged 45 to 54; 2.9 in those 55 to 64; 3.8 in those aged 65 to 74, and 4.8 in those aged 75 and older (P < .05, ANOVA [analysis of variance]).

CONCLUSION

Multimorbidity is common in the Canadian population and is strongly related to age.

Transition in Frailty State Among Elderly Patients After Vascular Surgery

BACKGROUND

Frailty in the vascular surgical ward is common and predicts poor surgical outcomes. The aim of this study was to analyze transitions in frailty state in elderly patients after vascular surgery and to evaluate influence of patient characteristics on this transition.

METHODS

Between 2014 and 2018, 310 patients, ≥65 years and scheduled for elective vascular surgery, were included in this cohort study. Transition in frailty state between preoperative and follow-up measurement was determined using the Groningen Frailty Indicator (GFI), a validated tool to measure frailty in vascular surgery patients. Frailty is defined as a GFI score ≥4. Patient characteristics leading to a transition in frailty state were analyzed using multivariable Cox regression analysis.

RESULTS

Mean age was 72.7 ± 5.2 years, and 74.5% were male. Mean follow-up time was 22.7 ± 9.5 months. At baseline measurement, 79 patients (25.5%) were considered frail. In total, 64 non-frail patients (20.6%) shifted to frail and 29 frail patients (9.4%) to non-frail. Frail patients with a high Charlson Comorbidity Index (HR = 0.329 (CI: 0.133-0.812), p = 0.016) and that underwent a major vascular intervention (HR = 0.365 (CI: 0.154-0.865), p = 0.022) had a significantly higher risk to remain frail after the intervention.

CONCLUSIONS

The results of this study, showing that after vascular surgery almost 21% of the non-frail patients become frail, may lead to a more effective shared decision-making process when considering treatment options, by providing more insight in the postoperative frailty course of patients.

AI and Big Data in Healthcare: Towards a More Comprehensive Research Framework for Multimorbidity

Multimorbidity refers to the coexistence of two or more chronic diseases in one person. Therefore, patients with multimorbidity have multiple and special care needs. However, in practice it is difficult to meet these needs because the organizational processes of current healthcare systems tend to be tailored to a single disease. To improve clinical decision making and patient care in multimorbidity, a radical change in the problem-solving approach to medical research and treatment is needed. In addition to the traditional reductionist approach, we propose interactive research supported by artificial intelligence (AI) and advanced big data analytics. Such research approach, when applied to data routinely collected in healthcare settings, provides an integrated platform for research tasks related to multimorbidity. This may include, for example, prediction, correlation, and classification problems based on multiple interaction factors. However, to realize the idea of this paradigm shift in multimorbidity research, the optimization, standardization, and most importantly, the integration of electronic health data into a common national and international research infrastructure is needed. Ultimately, there is a need for the integration and implementation of efficient AI approaches, particularly deep learning, into clinical routine directly within the workflows of the medical professionals.

Timing of Co-occurring Chronic Conditions in Children With Neurologic Impairment

BACKGROUND

Children with neurologic impairment (NI) are at risk for developing co-occurring chronic conditions, increasing their medical complexity and morbidity. We assessed the prevalence and timing of onset for those conditions in children with NI.

METHODS

This longitudinal analysis included 6229 children born in 2009 and continuously enrolled in Medicaid through 2015 with a diagnosis of NI by age 3 in the IBM Watson Medicaid MarketScan Database. NI was defined with an existing diagnostic code set encompassing neurologic, genetic, and metabolic conditions that result in substantial functional impairments requiring subspecialty medical care. The prevalence and timing of co-occurring chronic conditions was assessed with the Agency for Healthcare Research and Quality Chronic Condition Indicator system. Mean cumulative function was used to measure age trends in multimorbidity.

RESULTS

The most common type of NI was static (56.3%), with cerebral palsy (10.0%) being the most common NI diagnosis. Respiratory (86.5%) and digestive (49.4%) organ systems were most frequently affected by co-occurring chronic conditions. By ages 2, 4, and 6 years, the mean (95% confidence interval [CI]) numbers of co-occurring chronic conditions were 3.7 (95% CI 3.7-3.8), 4.6 (95% CI 4.5-4.7), and 5.1 (95% CI 5.1-5.2). An increasing percentage of children had ≥9 co-occurring chronic conditions as they aged: 5.3% by 2 years, 10.0% by 4 years, and 12.8% by 6 years.

CONCLUSIONS

Children with NI enrolled in Medicaid have substantial multimorbidity that develops early in life. Increased attention to the timing and types of multimorbidity in children with NI may help optimize their preventive care and case management health services.

Evaluating a cardiovascular disease risk management care continuum within a learning healthcare system: a prospective cohort study

BACKGROUND

Many patients now present with multimorbidity and chronicity of disease. This means that multidisciplinary management in a care continuum, integrating primary care and hospital care services, is needed to ensure high quality care.

AIM

To evaluate cardiovascular risk management (CVRM) via linkage of health data sources, as an example of a multidisciplinary continuum within a learning healthcare system (LHS).

DESIGN & SETTING

In this prospective cohort study, data were linked from the Utrecht Cardiovascular Cohort (UCC) to the Julius General Practitioners' Network (JGPN) database. UCC offers structured CVRM at referral to the University Medical Centre (UMC) Utrecht. JGPN consists of electronic health record (EHR) data from referring GPs.

METHOD

The cardiovascular risk factors were extracted for each patient 13 months before referral (JGPN), at UCC inclusion, and during 12 months follow-up (JGPN). The following areas were assessed: registration of risk factors; detection of risk factor(s) requiring treatment at UCC; communication of risk factors and actionable suggestions from the specialist to the GP; and change of management during follow-up.

RESULTS

In 52% of patients, ≥1 risk factors were registered (that is, extractable from structured fields within routine care health records) before UCC. In 12%-72% of patients, risk factor(s) existed that required (change or start of) treatment at UCC inclusion. Specialist communication included the complete risk profile in 67% of letters, but lacked actionable suggestions in 86%. In 29% of patients, at least one risk factor was registered after UCC. Change in management in GP records was seen in 21%-58% of them.

CONCLUSION

Evaluation of a multidisciplinary LHS is possible via linkage of health data sources. Efforts have to be made to improve registration in primary care, as well as communication on findings and actionable suggestions for follow-up to bridge the gap in the CVRM continuum.

Self-management strategies and comorbidities in chronic disease patients: associations with quality of life and depression

Self-management strategies are essential for improving prognosis in chronic illnesses. This study aimed to investigate the association between comorbidity and self-management strategies. A total of 700 patients with one or more chronic diseases including diabetes, dyslipidemia, hypertension, osteoporosis, chronic lung disease, chronic kidney disease and arthritis were enrolled. A questionnaire including the Smart Management Strategy for Health Assessment Tool Short Form (SAT), the Short Form-12, the McGill Quality of Life questionnaire, and the Patient Health Questionnaire-9 was administered to participants. The trend of each SAT according to number of comorbidities was evaluated, and the difference in quality of life and depression according to self-management strategies was examined in the model classified by the number of diseases. Self-management strategy scores tended to decrease as the number of comorbidities increased from one to four (p-value: 0.001 to 0.008). Regardless of the number of comorbidities, the MQOL score was higher in the good self-management strategy group (p: <0.001 to 0.016). The prevalence of mild depression was higher in patients with low self-management strategy, but the differences were not significant. Based on these findings, self-management strategies should be evaluated multidimensionally, and patients should be encouraged to develop effective self-management strategies to manage multiple chronic diseases.

Estimating disease prevalence from drug utilization data using the Random Forest algorithm

Background

Aggregated claims data on medication are often used as a proxy for the prevalence of diseases, especially chronic diseases. However, linkage between medication and diagnosis tend to be theory based and not very precise. Modelling disease probability at an individual level using individual level data may yield more accurate results.

Methods

Individual probabilities of having a certain chronic disease were estimated using the Random Forest (RF) algorithm. A training set was created from a general practitioners database of 276 723 cases that included diagnosis and claims data on medication. Model performance for 29 chronic diseases was evaluated using Receiver-Operator Curves, by measuring the Area Under the Curve (AUC).

Results

The diseases for which model performance was best were Parkinson’s disease (AUC = .89, 95% CI = .77–1.00), diabetes (AUC = .87, 95% CI = .85–.90), osteoporosis (AUC = .87, 95% CI = .81–.92) and heart failure (AUC = .81, 95% CI = .74–.88). Five other diseases had an AUC >.75: asthma, chronic enteritis, COPD, epilepsy and HIV/AIDS. For 16 of 17 diseases tested, the medication categories used in theory-based algorithms were also identified by our method, however the RF models included a broader range of medications as important predictors.

Conclusion

Data on medication use can be a useful predictor when estimating the prevalence of several chronic diseases. To improve the estimates, for a broader range of chronic diseases, research should use better training data, include more details concerning dosages and duration of prescriptions, and add related predictors like hospitalizations.

Factors affecting health-related quality of life among prostate cancer patients: A systematic review

INTRODUCTION

Prostate cancer is recognized as the leading cause of malignancy-related incidence and mortality in the male population. The treatment regimens have long-term effects detrimental to the patient's quality of life. Hence, this review was aimed to determine the overall HRQOL and its associated among prostate cancer patients.

METHODS

The review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The databases searched were PubMed, Embase, Google Scholar and Cumulative Index to the Nursing and Allied Literature (CINAHL), which provided articles that were critically examined, yielding 52 studies that met the inclusion criteria for the systematic review.

RESULTS

Out of 52 studies, 30 studies reported poor overall HRQOL in various domains after prostate cancer treatment. Contrastingly, 15 studies reported good overall quality of life after treatment. Among the various domains, sexual function was the most grossly affected functional score by the treatment modalities of prostate cancer. Nonetheless, seven studies showed that the absence of a significant change in the overall quality of life after treatment. According to the studies, older age, comorbidities, higher clinical stage, higher Gleason score, greater cancer severity, African American race, impaired mental health, neoadjuvant hormonal therapy and lower level of education were the major poor predictors of HRQOL among prostate cancer patients.

CONCLUSION

The overall HRQOL in prostate cancer patients was generally poor in various functional domains after treatment. Among the various domains, sexual function was the most grossly affected functional score by the treatment modalities of prostate cancer.

Interprofessional education and collaboration between general practitioner trainees and practice nurses in providing chronic care; a qualitative study

BACKGROUND

Effective interprofessional collaboration (IPC) is essential for the delivery of chronic care. Interprofessional education (IPE) can help support IPC skills. This makes IPE interesting for GP practices where chronic care is delivered by GPs together with practice nurses, especially for GP trainees who have to learn to collaborate with practice nurses during their training. The aim of this study is to gain insights in how IPE and IPC occur between GP trainees and practice nurses during the delivery of chronic care in GP training practices.

METHODS

We conducted a qualitative research using semi structured focus groups and interviews with GP trainees, practice nurses and GP supervisors. All respondents were primed to the subject of IPE as they had followed an interprofessional training on patient-centred communication. The verbatim transcripts of the focus groups and interviews were analysed using thematic analysis.

RESULTS

Despite the overall positive attitude displayed by respondents towards IPE and IPC, the occurrence of IPE and IPC in GP training practices was limited. Possible explanations for this are impeding factors such as limited knowledge, prejudice, lack of role models and a hierarchical organisational structure. Contributing to IPE and IPC use was the integration of IPE in daily practice, e.g. via recurring scheduled meetings.

CONCLUSION

We found a limited occurrence of IPE and IPC in GP training practices. Our results show a discrepancy between respondents enthusiasm for IPE and IPC and their actual behaviour. IPE activities have to be initiated in GP training practices, otherwise, despite good intentions, IPE and IPC will be ineffective.

Multimorbidity Patterns in the General Population: Results from the EpiChron Cohort Study

The correct management of patients with multimorbidity remains one of the main challenges for healthcare systems worldwide. In this study, we analyze the existence of multimorbidity patterns in the general population based on gender and age. We conducted a cross-sectional study of individuals of all ages from the EpiChron Cohort, Spain (1,253,292 subjects), and analyzed the presence of systematic associations among chronic disease diagnoses using exploratory factor analysis. We identified and clinically described a total of 14 different multimorbidity patterns (12 in women and 12 in men), with some relevant differences in the functions of age and gender. The number and complexity of the patterns was shown to increase with age in both genders. We identified associations of circulatory diseases with respiratory disorders, chronic musculoskeletal diseases with depression and anxiety, and a very consistent pattern of conditions whose co-occurrence is known as metabolic syndrome (hypertension, diabetes, obesity, and dyslipidaemia), among others. Our results demonstrate the potential of using real-world data to conduct large-scale epidemiological studies to assess the complex interactions among chronic conditions. This could be useful in designing clinical interventions for patients with multimorbidity, as well as recommendations for healthcare professionals on how to handle these types of patients in clinical practice.

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Multimorbidity in older people with intellectual disability

BACKGROUND

There is paucity of research from Australia about comorbidity in older people with intellectual disability (PwID). This paper examines the burden of chronic diseases and associated sociodemographic correlates in a cohort of PwID aged 60+.

METHODS

A cross-sectional survey was used with community-dwelling older PwID in urban/rural regions of two Australian states. Recruitment was undertaken via a multi-prong approach and each subject (N = 391; 236 urban/155 rural) personally interviewed.

RESULTS

Findings show older PwID experience considerable multimorbidity (X = 3.8; 53.5% had 2-6 conditions). Conditions included arthritis (40%), diabetes (26%), cardiovascular diseases (23.6%), asthma (16.1%), carcinomas (10.0%) and mental health disorders (34.5%).

CONCLUSIONS

There was significant multimorbidity in older PwID, with evolution of life trajectories of select conditions associated with socioeconomic disadvantage and heath facility access barriers. Greater scrutiny of progressive health debilitation leading into older age and increased engagement by healthcare systems is required earlier in the lives of PwID.

Patterns of Multimorbidity in Adults: An Association Rules Analysis Using the Korea Health Panel

This study aimed to identify the prevalence and patterns of multimorbidity among Korean adults. A descriptive study design was used. Of 11,232 adults aged 18 and older extracted from the 2014 Korean Health Panel Survey, 7118 had one or more chronic conditions. The chronic conditions code uses the Korean Standard Classification of Diseases. Association rule analysis and network analysis were conducted to identify patterns of multimorbidity among 4922 participants with multimorbidity. The prevalence of multimorbidity in the overall population was 34.8%, with a higher prevalence among women (40.8%) than men (28.6%). Hypertension had the highest prevalence in both men and women. In men, diabetes mellitus and hypertension yielded the highest probability of comorbidity (10.04%). In women, polyarthrosis and hypertension yielded the highest probability of comorbidity (12.51%). The results of the network analysis in four groups divided according to gender and age showed different characteristics for each group. Public health practitioners should adopt an integrated approach to manage multimorbidity rather than an individual disease-specific approach, along with different strategies according to age and gender groups.

Identifying subgroups of high-need, high-cost, chronically ill patients in primary care: A latent class analysis

Introduction

Segmentation of the high-need, high-cost (HNHC) population is required for reorganizing care to accommodate person-centered, integrated care delivery. Therefore, we aimed to identify and characterize relevant subgroups of the HNHC population in primary care by using demographic, biomedical, and socioeconomic patient characteristics.

Methods

This was a retrospective cohort study within a Dutch primary care group, with a follow-up period from September 1, 2014 to August 31, 2017. Chronically ill patients were included in the HNHC population if they belonged to the top 10% of care utilizers and/or suffered from multimorbidity and had an above-average care utilization. In a latent class analysis, forty-one patient characteristics were initially used as potential indicators of heterogeneity in HNHC patients’ needs.

Results

Patient data from 12 602 HNHC patients was used. A 4-class model was considered statistically and clinically superior. The classes were named according to the characteristics that were most dominantly present and distinctive between the classes (i.e. mainly age, household position, and source of income). Class 1 (‘older adults living with partner’) included 39.3% of patients, class 2 (‘older adults living alone’) included 25.5% of patients, class 3 (‘middle-aged, employed adults with family’) included 23.3% of patients, and class 4 (‘middle-aged adults with social welfare dependency’) included 11.9% of patients. Diabetes was the most common condition in all classes; the second most prevalent condition differed between osteoarthritis in class 1 (21.7%) and 2 (23.8%), asthma in class 3 (25.3%), and mood disorders in class 4 (23.1%). Furthermore, while general practitioner (GP) care utilization increased during the follow-up period in the classes of older adults, it remained relatively stable in the middle-aged classes.

Conclusions

Although the HNHC population is heterogeneous, distinct subgroups with relatively homogeneous patterns of mainly demographic and socioeconomic characteristics can be identified. This calls for tailoring care and increased attention for social determinants of health.

A Multicenter Study of Multimorbidity in Older Adult Inpatients in China

OBJECTIVES

Multimorbidity is common in older hospitalized adults. To date, however, few studies have addressed multimorbidity in the older population of Chinese inpatients. We aimed to investigate the multimorbidity rate and associated risk factors in older adult inpatients in China.

DESIGN, SETTING, PARTICIPANTS

This study was conducted in the medical wards of a tertiary-care hospital from. The patients were recruited aged between 60 to 101 (74.14±8.46) years.

MEASUREMENTS

Data were obtained from the China Comprehensive Geriatric Assessment Study, conducted in 2011-2012 in China. A total of 4,633 inpatients older than 60 years was recruited from 12 hospitals in 7 cities throughout China. The prevalence of comorbidity, distribution of common chronic diseases, and the associated risk factors were studied.

RESULTS

A total of 4,348 people aged 60 to 101 (74.14±8.46) years completed questionnaires. The average frequency of multimorbidity was 69.3% (95% CI, 67.9% to 70.6%). The prevalence of multimorbidity increased with age and was higher in men (71.6%; 95% CI, 69.9% to 73.3%) than in women (65.3%, 95% CI 63.0% to 67.6%), and higher in the northern region (71.7%, 95% CI 69.9% to 73.5%) than in the southern region (66.0%; 95% CI, 63.8% to 68.1%). The most frequent chronic diseases were hypertension, coronary heart disease, diabetes, cataract, and stroke. Area (OR=0.556; 95% CI, 0.465 to 0.666), region (OR=0.834; 95% CI, 0.723 to 0.962), body mass index (BMI) (OR=1.124; 95% CI, 1.017 to 1.242), and impairment of activities of daily living (OR=0.911; 95% CI, 0.855 to 0.970) were independent factors associated with multimorbidity.

CONCLUSIONS

Multimorbidity is common in older Chinese inpatients with a national prevalence of 69.3% that increases in line with age. Age, region, area, BMI, and daily activities were independent factors significantly associated with multimorbidity in older inpatients. Clinicians should therefore focus more attention on multimorbidity.

THE ASSESSMENT OF COMORBID PATHOLOGY IN CLEAN-UP WORKERS OF THE ACCIDENT CONSEQUENCES AT THE CHORNOBYL NPP HAVING CARDIOVASCULAR DISEASES

OBJECTIVE

Analysis of comorbid pathology based on the use of methods for its quantitative assessment in personswho were exposed to radiation because of the Chornobyl accident.

MATERIALS AND METHODS

Comorbid pathology was studied in 608 men, including 420 clean-up workers (CW) of theaccident consequences at the Chornobyl NPP (main group) and 188 non-irradiated persons (control group - CG). Allpatients had cardiovascular diseases as their main pathology and were examined in the cardiology department ofthe NRCRM hospital during 2011-2019. The groups did not differ by age, either at the beginning of the accident orat the time of their last examination. Patients of both groups before the accident were practically healthy peopleand were not registered at the dispensary. The Cumulative Illness Rating Scale (CIRS) was used to quantify comorbid pathology.

RESULTS

Comorbid pathology was detected in 418 CW (99.5 %) and 183 patients of CG (99.3 %). The total score inCW (10.3 ± 2.9) units significantly (р = 0.000) exceeded the same index in non-irradiated patients (8.8 ± 3.0) units,as well as the mean number of CIRS categories, whose level severity was 1 point (3.3 ± 1.7 vs. 2.6 ± 1.5, р = 0.000),2 points (1.8 ± 1.0 vs. 1.6 ± 1.0, p = 0.032) and 3-4 points (1.2 ± 0.8 vs. 1.0 ± 0.9, р = 0.062). In contrast, the meanvalue of the categories with zero score, i.e. without diseases, was more common in CG (7.8 ± 1.8 vs. 8.8 ± 1.7,р = 0.000). The most common pathology in CW and CG were heart (98.3 % vs. 94.7 %, р < 0.05) and vascular diseases(92.9 % vs. 87.8 %, р > 0.05), followed by diseases of nervous system (79.0 % vs. 57.4 %, р <0.001), musculoskeletal system and skin (69.8 % vs. 56.9 %, р < 0.01), endocrine (56.0 % vs. 49,5 %, р > 0.05) and the respiratory system (53.8 % vs. 53.7 %, р > 0.05) and liver (51.2 % vs. 36.2 %, р < 0.001), which were detected more than in halfpatients of the main group. Diseases of the kidneys (3.3 % vs. 4.8 %, р > 0.05) and lower gastrointestinal tract(3.3 % vs. 0.5 %, р < 0.01) were quite rare. The incidence of the other four CIRS categories was 18.6-34 %. The totalscore in subgroups with different ages varied in descending order of mean values as follows: CW > 65 years (10.5 ± 2.9)units, CW < 65 years (9.9 ± 2.8) units, CG > 65 years (9.5 ± 2.8) units and CG < 65 years (7.8 ± 2.9) units with significant differences both between age subgroups in each of the groups and between CW and CG older subgroups.

CONCLUSIONS

Quantitative assessment of comorbidity by CIRS showed that in persons irradiated during their emergency work due to the Chornobyl accident, the incidence of combined pathology of such organ systems as cardiovascular, nervous, endocrine, hematopoietic, urogenital, musculoskeletal, gastrointestinal, liver and kidneys wassignificantly higher than in non-irradiated patients. In irradiated patients, the course of comorbid pathology wasmore severe for each system and in general, reflecting higher values of the total CIRS score. Both among CW andnon-irradiated controls, higher values of the total comorbidity score were observed in patients 65 years and older,compared with younger individuals. In both age subgroups of CW the total score was higher than in patients of thecontrol group.

[Patients with chronic diseases in emergency rooms in Germany : Cross-sectional analysis of consultations, reasons for use, and discharge diagnosis]

BACKGROUND

The number of patients in emergency rooms without a medical emergency is increasing. Outpatient services for mutual support and relief between the in-patient and out-patient sector are not yet fully established.

AIM OF THE WORK

The aim was to determine the extent to which patients in emergency rooms have real medical emergencies by comparing patients with at least two and those with a maximum of one chronic illness. An additional aim was to identify factors influencing the previous use of outpatient structures.

MATERIAL AND METHODS

The study participants included emergency room patients from the cross-sectional study "PiNo-Nord." All persons in five emergency rooms in northern Germany between October 2015 and July 2016 who were not treated as "immediate" or "very urgent" were interviewed. An exploratory data analysis and multivariate logistic regression were performed.

RESULTS

The 293 patients with ≥2 chronic diseases were just as often a medical emergency compared to the 847 patients with a maximum of 1 chronic disease. The most frequent occasions for consultation were musculoskeletal trauma (33%, n = 293 vs. 42%, n = 847) or trauma of the skin (11%, n = 293 vs. 13%, n = 847). In both groups, the general practitioner or specialist caregiver, as well as diagnostic or treatment options, rarely played a role in visiting the emergency department. The strongest predictors of previous outpatient treatment were the duration of the appeal in the last six months, a high subjective treatment urgency, the presence of at least two chronic conditions, and a consultation event concerning the musculoskeletal injuries.

CONCLUSIONS

In both patient groups, no evidence of unnecessary visits to the emergency room was found. For the most part, outpatient structures are used in advance and the emergency department is only visited in the event of an actual medical emergency.

Correlation of the quantitative level of MGMT promoter methylation and overall survival in primary diagnosed glioblastomas using the quantitative MethyQESD method

AIMS

O(6)-methylguanine-DNA-methyltransferase (MGMT) promoter methylation is a high predictive factor for therapy results of temozolomide in patients with glioma. The objective of this work was to analyse the impact of MGMT promoter methylation in patients with primary diagnosed glioblastoma (GBM) relating to survival using a quantitative method (methylation quantification of endonuclease-resistant DNA, MethyQESD) by verifying a cut-off point for MGMT methylation provided by the literature (</≥10%) and calculating an optimal cut-off.

METHODS

67 patients aged 70 years or younger, operated between January 2013 and December 2015, with newly diagnosed IDH wild-type GBM and clinical follow-up were retrospectively investigated in this study. A known MGMT promoter methylation status was the inclusion criteria.

RESULTS

Median overall survival (OS) was 16.9 months. Patients who had a methylated MGMT promoter region of ≥10% had an improved OS compared with patients with a methylated promoter region of <10% (p=0.002). Optimal cut-off point for MGMT promoter methylation was 11.7% (p=0.012).

CONCLUSION

The results confirm that the quantitative level of MGMT promoter methylation is a positive prognostic factor in newly diagnosed patients with GBM. The cut-off provided by the literature (</≥10%) and the calculated optimal cut-off value of 11.7% give a statistically significant separation. Hence, MethyQESD is a reliable method to calculate MGMT promoter methylation in GBM.