Operationalizing multimorbidity and autonomy for health services research in aging populations--the OMAHA study

How family physicians in Singapore recognise complexity during consultations: a qualitative study

BACKGROUND

The prevalence of persons with complex needs in Singapore is rising. Poor understanding of what constitutes complexity impedes the identification of care gaps and development of interventions to improve care for these individuals. We aim to identify the characteristics contributing to complexity in primary care, from the Family Physicians' (FP) perspectives.

METHODS

Focus group discussions (FGDs) were conducted from January to September 2021 with experienced FPs across 14 study sites, employing a qualitative descriptive approach based on a complexity framework. Data were coded independently and categorised using thematic analysis by two independent investigators.

RESULTS

Five FGDs were conducted with 18 FPs aged 32 to 57 years old working in different primary care settings, with a mean of 13.5 years of primary care experience. Participants emphasised the need for a unified definition of complexity. Complexity is characterised by the presence of issues spanning across two or more domains (medical, psychological, social or behavioural) that adversely impact medical care and outcomes. Persons with complex needs contrast with persons with medically difficult issues. Medical domain issues include the number of active medical problems, poor chronic disease control, treatment interactions, ill-defined symptoms, management of end-of-life conditions and functional impairment. Psychological domain issues include the presence of mental health conditions or cognitive impairment. Social domain issues include the lack of social support, competing social responsibilities and financial issues, while behavioural domain issues include a lack of trust in healthcare workers, fixed health beliefs and poor health literacy.

CONCLUSION

Recognising the medical, psychological, social and behavioural factors that contribute to complexity aids in discerning the diverse needs of individuals with complex needs. This underscores the need for additional support in these pertinent areas.

Study on Health of Older People in Germany (Gesundheit 65+): objectives, design and implementation

Background

The longitudinal population-based study Gesundheit 65+ aimed to close data gaps on health and well-being of older adults in Germany in times of the COVID-19 pandemic.

Methods

The target population comprised persons 65 years and older permanently residing in Germany and with sufficient German language skills. Proxy interviews were possible and consent from legal representatives was obtained as necessary in order to enable participation of physically or cognitively impaired persons. A two-stage sampling process, was used to draw 128 primary sample points (PSUs) and within these PSUs sex- and age-stratified random samples were drawn from population registries. A mixed-mode design was applied to contact the study population and for data collection. Data were collected between June 2021 and April 2023. Participants were surveyed a total of four times at intervals of four months. At month 12 participants were offered a home visit including a non-invasive examination. Data on all-cause mortality and information on neighborhood social and built environment as well as health insurance data will be linked to primarily collected data at the individual level.

Discussion

Results will inform health politicians and other stakeholders in the care system on health and health care needs of older people in Germany.

Health status of the old and very old people in Germany: results of the Gesundheit 65+ study

Background

The demographic change makes comprehensive health reporting on health at older age an important topic.

Methods

Gesundheit 65+ is a longitudinal epidemiological study on the health status of persons aged 65 and older in Germany. Based on a two-stage stratified random sample from 128 local population registers, 3,694 persons participated in the baseline survey between June 2021 and April 2022 (47.9 % women, mean age 78.8 years). Weighted prevalences for 19 indicators of the baseline survey are presented overall and by age, sex, education and region of residence.

Results

Overall, 52.0 % of all participants of the baseline survey reported to be in good or very good health, and 78.5 % reported high or very high satisfaction with their life. This was in contrast to the large number of health/functional limitations whose prevalences ranged from 5.3 % for severe visual limitations to 69.2 % for multimorbidity. The health status of women was clearly worse than that of men, and the health status of persons aged 80 and older was worse than between 65 and 79 years of age. There was a clear educational gradient evident in the health status, but there were no differences between West and East Germany.

Conclusions

Gesundheit 65+ provides a comprehensive database for description of the health status of old and very old people in Germany, on the basis of which recommendations for action for policy and practice can be derived.

Analysis of the evidence-practice gap to facilitate proper medical care for the elderly: investigation, using databases, of utilization measures for National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB)

As Japan becomes a super-aging society, presentation of the best ways to provide medical care for the elderly, and the direction of that care, are important national issues. Elderly people have multi-morbidity with numerous medical conditions and use many medical resources for complex treatment patterns. This increases the likelihood of inappropriate medical practices and an evidence-practice gap. The present study aimed to: derive findings that are applicable to policy from an elucidation of the actual state of medical care for the elderly; establish a foundation for the utilization of National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB), and present measures for the utilization of existing databases in parallel with NDB validation.

Cross-sectional and retrospective cohort studies were conducted using the NDB built by the Ministry of Health, Labor and Welfare of Japan, private health insurance claims databases, and the Kyoto University Hospital database (including related hospitals). Medical practices (drug prescription, interventional procedures, testing) related to four issues—potential inappropriate medication, cancer therapy, chronic kidney disease treatment, and end-of-life care—will be described. The relationships between these issues and clinical outcomes (death, initiation of dialysis and other adverse events) will be evaluated, if possible.

A Systematic Review of Conceptual Frameworks of Medical Complexity and New Model Development

BACKGROUND

Patient complexity is often operationalized by counting multiple chronic conditions (MCC) without considering contextual factors that can affect patient risk for adverse outcomes.

OBJECTIVE

Our objective was to develop a conceptual model of complexity addressing gaps identified in a review of published conceptual models.

DATA SOURCES

We searched for English-language MEDLINE papers published between 1 January 2004 and 16 January 2014. Two reviewers independently evaluated abstracts and all authors contributed to the development of the conceptual model in an iterative process.

RESULTS

From 1606 identified abstracts, six conceptual models were selected. One additional model was identified through reference review. Each model had strengths, but several constructs were not fully considered: 1) contextual factors; 2) dynamics of complexity; 3) patients' preferences; 4) acute health shocks; and 5) resilience. Our Cycle of Complexity model illustrates relationships between acute shocks and medical events, healthcare access and utilization, workload and capacity, and patient preferences in the context of interpersonal, organizational, and community factors.

CONCLUSIONS/IMPLICATIONS

This model may inform studies on the etiology of and changes in complexity, the relationship between complexity and patient outcomes, and intervention development to improve modifiable elements of complex patients.

Baseline participation in a health examination survey of the population 65 years and older: who is missed and why?

Background

Public health monitoring depends on valid health and disability estimates in the population 65+ years. This is hampered by high non-participation rates in this age group. There is limited insight into size and direction of potential baseline selection bias.

Methods

We analyzed baseline non-participation in a register-based random sample of 1481 inner-city residents 65+ years, invited to a health examination survey according to demographics available for the entire sample, self-report information as available and reasons for non-participation. One year after recruitment, non-responders were revisited to assess their reasons.

Results

Five groups defined by participation status were differentiated: participants (N = 299), persons who had died or moved (N = 173), those who declined participation, but answered a short questionnaire (N = 384), those who declined participation and the short questionnaire (N = 324), and non-responders (N = 301). The results confirm substantial baseline selection bias with significant underrepresentation of persons 85+ years, persons in residential care or from disadvantaged neighborhoods, with lower education, foreign citizenship, or lower health-related quality of life. Finally, reasons for non-participation could be identified for 78 % of all non-participants, including 183 non-responders.

Conclusion

A diversity in health problems and barriers to participation exists among non-participants. Innovative study designs are needed for public health monitoring in aging populations.

[Skin health promotion in the elderly]

BACKGROUND

Skin aging is associated with anatomical and physiological changes. These changes are not pathological; nevertheless, reduced functional skin capacity increases the susceptibility to skin diseases and functional disorders. Especially in old age, the clinical manifestation of skin changes differs greatly between individuals.

PURPOSE

This contribution focuses on a critical reflection of the concept of preventative skin care and skin health promotion in the aged.

RESULTS

Preventive skin care in the aged includes all activities to cleanse and care for the skin which contribute to health promotion and which reduce the probability developing skin disorders or diseases. Preventive skin care in the aged can be classified into primary, secondary, and tertiary prevention, but the empirical evidence supporting individual interventions is heterogeneous.

CONCLUSION

There are no formally developed guidelines or recommendations for basic skin care in the aged. Thus, preventive skin care in the elderly is very likely to be underused.

German health interview and examination survey for adults (DEGS) - design, objectives and implementation of the first data collection wave

BACKGROUND

The German Health Interview and Examination Survey for Adults (DEGS) is part of the recently established national health monitoring conducted by the Robert Koch Institute. DEGS combines a nationally representative periodic health survey and a longitudinal study based on follow-up of survey participants. Funding is provided by the German Ministry of Health and supplemented for specific research topics from other sources.

METHODS/DESIGN

The first DEGS wave of data collection (DEGS1) extended from November 2008 to December 2011. Overall, 8152 men and women participated. Of these, 3959 persons already participated in the German National Health Interview and Examination Survey 1998 (GNHIES98) at which time they were 18-79 years of age. Another 4193 persons 18-79 years of age were recruited for DEGS1 in 2008-2011 based on two-stage stratified random sampling from local population registries. Health data and context variables were collected using standardized computer assisted personal interviews, self-administered questionnaires, and standardized measurements and tests. In order to keep survey results representative for the population aged 18-79 years, results will be weighted by survey-specific weighting factors considering sampling and drop-out probabilities as well as deviations between the design-weighted net sample and German population statistics 2010.

DISCUSSION

DEGS aims to establish a nationally representative data base on health of adults in Germany. This health data platform will be used for continuous health reporting and health care research. The results will help to support health policy planning and evaluation. Repeated cross-sectional surveys will permit analyses of time trends in morbidity, functional capacity levels, disability, and health risks and resources. Follow-up of study participants will provide the opportunity to study trajectories of health and disability. A special focus lies on chronic diseases including asthma, allergies, cardiovascular conditions, diabetes mellitus, and musculoskeletal diseases. Other core topics include vaccine-preventable diseases and immunization status, nutritional deficiencies, health in older age, and the association between health-related behavior and mental health.

[Geriatric multimorbidity in claims data - part 2 : diagnoses of hospitals and diagnoses from physicians in the ambulatory setting]

BACKGROUND

Due to demographics, characteristic multimorbidity in geriatric patients is resulting in increased social, medical, and healthcare challenges. Geriatric multimorbidity (GM) can be defined as the simultaneous occurrence of at least two diseases that require medical care with an interdisciplinary focus on independence in activities of daily living. Typical conditions of GM are, e.g., incontinence, cognitive impairment, frailty, and decubitus.

MATERIAL AND METHODS

Part 2 of this study is based on claims data of 240,502 AOK insurants (AOK is one of the major health insurance companies of the German statutory health insurance system) aged ≥ 60 years with at least one admission to a hospital with a geriatric ward. Geriatric conditions (GCs) were ascertained in two ways: diagnoses from physicians in the ambulant care setting and diagnoses in a hospital setting in 2008. A total of 15 GC were assessed using diagnoses based on ICD-10 codes (as per suggestion from scientific geriatric societies). An insurant was defined as a person with GM, if he/she had at least two GCs.

RESULTS

The proportion of GCs in ambulant or inpatient diagnoses of 240,502 insurants varied significantly in most cases. For specific GCs, considerably higher proportions of ambulant diagnoses (e.g., pain, impairment of vision, or hearing) or for inpatient diagnoses (e.g., electrolyte or fluid metabolism disorders, malnutrition, incontinence) were identified. Only on rare occasions were small differences observed comparing the proportions of specific GCs in the diagnoses of the two different care sectors. This finding reduces considerably the accordance between the two care sectors with reference to the presence or absence of a GC for ambulant or inpatient diagnoses. The main agreement was with the non-coding of specific GCs, not with ambulant or inpatient diagnoses. Insurants with a geriatric hospital admission or certain care level (level ≥ 1) generally had higher proportions for specific GCs for inpatient and ambulant diagnoses than non-geriatric treated insurants or insurants without a certain care level. Of the geriatric treated insurants and those with certain care levels, 90% were characterized by the presence of GM for both ambulant or inpatient diagnoses. This percentage is remarkably higher than for patients who featured no geriatric treatment or had no certain care level.

CONCLUSION

The inclusion of ambulant diagnoses in addition to inpatient diagnosis offers comprehensive possibilities to identify insurants with GM in claims data. The contribution of the diagnoses of both care sectors for the identification of GC and GM varies with regard to attribute and insurant orientation. Furthermore, significant attribute-oriented overlap of insurants claiming geriatric treatments and insurants with certain care levels became visible, which can open new possibilities for simpler identification of a portion of patients with GM.

[Autonomy despite multimorbidity in old age--the Berlin-based AMA research consortium]

The proportion of the population with multiple illnesses increases with age and growing numbers of people are now living to a very old age. Despite medical progress and improved living conditions, many old people have to deal with physical, psychological, and social impairments. It is a crucial challenge for health and social policy to support the elderly with health-related impairments in their desire to lead as independent a life as possible. Against this background the research consortium Autonomy Despite Multimorbidity in Old Age (AMA I) examined the extent to which the self-determined life style of multimorbid old and very old persons can be supported and maintained. In order to reflect the diversity of life worlds of the elderly, the study sample included participants who were not notably impaired in their everyday functioning, participants in need of nursing care and participants with cognitive impairments. Moreover, the sample comprised both older persons who were still living in their own homes and nursing home residents. The studies conducted within the AMA framework focused on the resources available to old persons living in different situations and on how these resources can be strengthened. This article presents findings from the first phase of funding of the AMA research consortium. In a second phase of funding (2011-2013, AMA II), sustainable practice-based interventions are being developed to mobilize resources which can help multimorbid older persons to maintain their autonomy and the practical viability of these interventions will be tested.

Validation of a new patient-generated questionnaire for quality of life in an urban sample of elder residents

PURPOSE

To provide evidence for the validity of the Fragebogen zur Lebensqualität multimorbider älterer Menschen (FLQM; English: Quality of life in elders with multimorbidity), a new tool for the assessment of life-satisfaction as a subjective indicator of quality of life in old age.

METHODS

The FLQM measures overall life-satisfaction based on those self-generated domains in life that are most important to the respondent. Construct validity (correlations with convergent and divergent scales) and differential validity (subgroup differences with respect to age and limitations in everyday functioning) were analyzed in an urban sample of older adults (n = 299; 54.6% male; Mean (age) = 75.65 years, SD = 6.57).

RESULTS

Correlations of FLQM with measures of similar constructs were close (r = 0.35-0.50; p < 0.001). There were no age-group differences. However, subjects with self-reported impairment in functioning scored significantly lower on the FLQM. Also, the relationship between FLQM and self-rated health was close (r = 0.44; p < 0.001).

CONCLUSIONS

The FLQM is a valid assessment of older peoples' life-satisfaction. The focus on domains of utmost individual importance seems to link the FLQM to self-rated health more closely than other ratings of global life-satisfaction. Further investigation into the qualitative information obtained by the FLQM is desirable in order to explain individual compositions of life-satisfaction and overall quality of life.

Individualized measurement of quality of life in older adults: development and pilot testing of a new tool

We describe theoretical background, development, and piloting of a measure for quality of life in older adults that specifically takes into account the subjective perspective. Although quality of life is usually subjectively assessed, normative thresholds for "the good life" are most often set by a third party. The new tool FLQM asks for respondents to name, rate, and weight those domains in life that are most important for their life-satisfaction solely from their own point of view. Construct validity was pilot-tested in two samples of elders (N₁ = 44; N₂ = 90). Correlations were in the medium range in both studies and support the questionnaire's validity. There were no age or gender differences on total score. However, in Study 1 as well as in Study 2 older subjects named significantly fewer domains than did younger participants. Further, in Study 1 the overall number of distinct domains generated by the participants diminished with age-the "interindividual pool of domains" shrank. Implications of this age-associated narrowing of domainscope are discussed on a background of adaptation theories. Concluding, the new questionnaire seems apt to assess older peoples' quality of life even in a physically very ill population, but needs further testing, especially regarding its reliability. This is currently being undertaken in a larger longitudinal sample to assure psychometric properties.