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Swan AA, Kennedy E, Cooper DB, Amuan ME, Mayo J, Tate DF, Song K, Eapen BC, Van Cott AC, Lopez MR, Pugh MJ. Comorbidity and polypharmacy impact neurobehavioral symptoms and symptom validity failure among post-9/11 veterans with mild traumatic brain injury. Front Neurol 2023; 14:1228377. [PMID: 37538260 PMCID: PMC10395329 DOI: 10.3389/fneur.2023.1228377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 06/26/2023] [Indexed: 08/05/2023] Open
Abstract
Objective The study aimed to examine the association between post-concussive comorbidity burdens [post-traumatic stress disorder (PTSD), depression, and/or headache] and central nervous system (CNS) polypharmacy (five or more concurrent medications) with reported neurobehavioral symptoms and symptom validity screening among post-9/11 veterans with a history of mild traumatic brain injury (mTBI). Setting Administrative medical record data from the Department of Veterans Affairs (VA) were used in the study. Participants Post-9/11 veterans with mTBI and at least 2 years of VA care between 2001 and 2019 who had completed the comprehensive traumatic brain injury evaluation (CTBIE) were included in the study. Design Retrospective cross-sectional design was used in the study. Main measures Neurobehavioral Symptom Inventory (NSI), International Classification of Diseases, Ninth Revision, and Clinical Modification diagnosis codes were included in the study. Results Of the 92,495 veterans with a history of TBI, 90% had diagnoses of at least one identified comorbidity (PTSD, depression, and/or headache) and 28% had evidence of CNS polypharmacy. Neurobehavioral symptom reporting and symptom validity failure was associated with comorbidity burden and polypharmacy after adjusting for sociodemographic characteristics. Veterans with concurrent diagnoses of PTSD, depression, and headache were more than six times more likely [Adjusted odds ratio = 6.55 (99% CI: 5.41, 7.92)]. to fail the embedded symptom validity measure (Validity-10) in the NSI. Conclusion TBI-related multimorbidity and CNS polypharmacy had the strongest association with neurobehavioral symptom distress, even after accounting for injury and sociodemographic characteristics. Given the regular use of the NSI in clinical and research settings, these findings emphasize the need for comprehensive neuropsychological evaluation for individuals who screen positively for potential symptom overreporting, the importance of multidisciplinary rehabilitation to restore functioning following mTBI, and the conscientious utilization of symptom validity measures in research efforts.
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Affiliation(s)
- Alicia A. Swan
- Polytrauma Rehabilitation Center, South Texas Veterans Health Care System, San Antonio, TX, United States
- Department of Psychology, The University of Texas at San Antonio, San Antonio, TX, United States
| | - Eamonn Kennedy
- Veterans Affairs Salt Lake City Health Care System, Informatics Decision Enhancement and Analytic Sciences Center of Innovation, Salt Lake City, UT, United States
- Division of Epidemiology, University of Utah School of Medicine Department of Internal Medicine, Salt Lake City, UT, United States
- University of Utah School of Medicine Department of Neurology, Salt Lake City, UT, United States
| | - Douglas B. Cooper
- Polytrauma Rehabilitation Center, South Texas Veterans Health Care System, San Antonio, TX, United States
- Departments of Rehabilitation Medicine and Psychiatry, The University of Texas Health San Antonio, San Antonio, TX, United States
| | - Megan E. Amuan
- Veterans Affairs Salt Lake City Health Care System, Informatics Decision Enhancement and Analytic Sciences Center of Innovation, Salt Lake City, UT, United States
- Division of Epidemiology, University of Utah School of Medicine Department of Internal Medicine, Salt Lake City, UT, United States
| | - Jamie Mayo
- Veterans Affairs Salt Lake City Health Care System, Informatics Decision Enhancement and Analytic Sciences Center of Innovation, Salt Lake City, UT, United States
- Division of Epidemiology, University of Utah School of Medicine Department of Internal Medicine, Salt Lake City, UT, United States
| | - David F. Tate
- Veterans Affairs Salt Lake City Health Care System, Informatics Decision Enhancement and Analytic Sciences Center of Innovation, Salt Lake City, UT, United States
- University of Utah School of Medicine Department of Neurology, Salt Lake City, UT, United States
| | - Kangwon Song
- Augusta University Medical Center, Augusta University, Augusta, GA, United States
| | - Blessen C. Eapen
- Department of Physical Medicine and Rehabilitation, VA Greater Los Angeles Healthcare System, Los Angeles, CA, United States
- Division of Physical Medicine and Rehabilitation, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Anne C. Van Cott
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, United States
- Department of Veterans Affairs, Pittsburgh Healthcare System, Pittsburgh, PA, United States
| | - Maria R. Lopez
- Bruce Carter Hospital, Miami Veterans Health Administration, Miami, FL, United States
- Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Mary Jo Pugh
- Veterans Affairs Salt Lake City Health Care System, Informatics Decision Enhancement and Analytic Sciences Center of Innovation, Salt Lake City, UT, United States
- Division of Epidemiology, University of Utah School of Medicine Department of Internal Medicine, Salt Lake City, UT, United States
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Lun P, Law F, Ho E, Tan KT, Ang W, Munro Y, Ding YY. Optimising prescribing practices in older adults with multimorbidity: a scoping review of guidelines. BMJ Open 2021; 11:e049072. [PMID: 34907045 PMCID: PMC8671917 DOI: 10.1136/bmjopen-2021-049072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Inappropriate polypharmacy occurs when multiple medications are prescribed without clear indications or where harms outweigh their benefits. The aims of this scoping review are to (1) identify prescribing guidelines that are available for older adults with multimorbidity and (2) to identify cross-cutting themes used in these guidelines. DESIGN Scoping review. DATA SOURCES PubMed, Embase, Web of Science, the Cochrane Library databases, Cumulative Index to Nursing and Allied Health Literature, grey literature sources, six key geriatrics journals, and reference lists of identified review papers. The search was conducted in November 2018 and updated in September 2019. STUDY SELECTION General prescribing guidelines tailored to or for adults including older adults with multimorbidity. DATA EXTRACTION Data for publication description, guideline characteristics, information for users and criteria were extracted. The synthesis contains summarised qualitative descriptions of the studies and guideline characteristics as well as identified cross-cutting themes. RESULTS Our search strategy yielded 10 427 unique citations, of which 70 fulfilled the inclusion criteria for synthesis. Among these, there were 61 unique guidelines and tools which used implicit, explicit, mixed or other approaches in the prescriber decision-making process. There are 11 cross-cutting themes identified in the guidelines. Prescriber-related themes are: conduct a comprehensive assessment before prescribing, identify patients' needs, goals and priorities, adopt shared decision-making, consider evidence-based recommendations, use clinical prescribing tools, incorporate multidisciplinary inputs and embrace technology-enabled prescribing. Wider organisation-related and system-related themes related to education, training and the work environment are also identified. CONCLUSIONS From guidelines and tools identified, eleven cross-cutting themes provide a usable knowledge base when seeking to optimise prescribing among older adults with multimorbidity. Incorporating these themes in an approach that uses mixed criteria and implementation information could facilitate greater uptake of published prescribing recommendations.
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Affiliation(s)
- Penny Lun
- Geriatric Education and Research Institute, Singapore
| | - Felicia Law
- Geriatric Medicine, National Healthcare Group Woodlands Health Campus, Singapore
| | - Esther Ho
- Geriatric Medicine, Tan Tock Seng Hospital, Singapore
| | | | - Wendy Ang
- Pharmacy, Changi General Hospital, Singapore
| | - Yasmin Munro
- Medical Library, Lee Kong Chian School of Medicine, Singapore
| | - Yew Yoong Ding
- Geriatric Education and Research Institute, Singapore
- Geriatric Medicine, Tan Tock Seng Hospital, Singapore
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3
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Ritchie CS, Garrett SB, Thompson N, Miaskowski C. Unintended Consequences of Opioid Regulations in Older Adults with Multiple Chronic Conditions. THE GERONTOLOGIST 2020; 60:1343-1352. [PMID: 32222760 PMCID: PMC7491430 DOI: 10.1093/geront/gnaa016] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND AND OBJECTIVES The opioid epidemic has led to substantive regulatory and policy changes. Little is known about how these changes have impacted older adults, especially those with chronic pain and multiple chronic conditions (MCC). We sought to understand the experiences of older adults with chronic pain and MCC in the context of the opioid epidemic and policy responses to it. RESEARCH DESIGN AND METHODS Purposive sampling of older adults in a West Coast metropolitan area. Semistructured in-depth interviews lasting 45-120 min were digitally recorded and transcribed. Responses were analyzed using the constant comparative method. Participants were 25 adults aged 65 years and greater with three or more self-reported medical conditions and pain lasting for more than 6 months. RESULTS Respondents' accounts revealed numerous unintended consequences of the opioid epidemic and its policy responses. We identified four main themes: changes to the patient-clinician relationship; lack of patient agency and access in pain management; patient ambivalence and anxiety about existing opioid treatment/use; and patient concerns about future use. DISCUSSION AND IMPLICATIONS Older adults have high rates of chronic pain and MCC that may reduce their pain management options. The opioid epidemic and policies addressing it have the potential to negatively affect patient-clinician relationships and patients' pain self-management. Clinicians may be able to mitigate these unintended consequences by actively conveying respect to the patient, empowering patients in their pain self-management activities, and proactively addressing worries and fears patients may own related to their current and future pain management regimens.
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Affiliation(s)
- Christine S Ritchie
- The Mongan Institute and the Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston
| | - Sarah B Garrett
- Division of Geriatrics, University of California, San Francisco
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
| | - Nicole Thompson
- Osher Center for Integrative Medicine, University of California, San Francisco
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Pedersen RA, Petursson H, Hetlevik I. Stroke follow-up in primary care: a Norwegian modelling study on the implications of multimorbidity for guideline adherence. BMC FAMILY PRACTICE 2019; 20:138. [PMID: 31627726 PMCID: PMC6798338 DOI: 10.1186/s12875-019-1021-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 09/03/2019] [Indexed: 11/16/2022]
Abstract
Background Specialized acute treatment and high-quality follow-up is meant to reduce mortality and disability from stroke. While the acute treatment for stroke takes place in hospitals, the follow-up of stroke survivors largely takes place in general practice. National guidelines give recommendations for the follow-up. However, previous studies suggest that guidelines are not sufficiently adhered to. It has been suggested that this might be due to the complexity of general practice. A part of this complexity is constituted by patients’ multimorbidity; the presence of two or more chronic conditions in the same person. In this study we investigated the extent of multimorbidity among stroke survivors residing in the communities. The aim was to assess the implications of multimorbidity for the follow-up of stroke in general practice. Methods The study was a cross sectional analysis of the prevalence of multimorbidity among stroke survivors in Mid-Norway. We included 51 patients, listed with general practitioners in 18 different clinics. The material consists of the general practitioners’ medical records for these patients. The medical records for each patient were reviewed in a search for diagnoses corresponding to a predefined list of morbidities, resulting in a list of chronic conditions for each participant. These 51 lists were the basis for the subsequent analysis. In this analysis we modelled different hypothetical patients and assessed the implications of adhering to all clinical guidelines affecting their diseases. Result All 51 patients met the criteria for multimorbidity. On average the patients had 4.7 (SD: 1.9) chronic conditions corresponding to the predefined list of morbidities. By modelling implications of guideline adherence for a patient with an average number of co-morbidities, we found that 10–11 annual consultations with the general practitioner were needed for the follow-up of the stable state of the chronic conditions. More consultations were needed for patients with more complex multimorbidity. Conclusions Multimorbidity had a clear impact on the basis for the follow-up of patients with stroke in general practice. Adhering to the guidelines for each condition is challenging, even for patients with few co-morbidities. For patients with complex multimorbidity, adhering to the guidelines is obviously unmanageable.
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Affiliation(s)
- Rune Aakvik Pedersen
- General Practice Research Unit, Department of Public Health and Nursing, NTNU, Norwegian University of Science and Technology, PO Box 8905 MTFS, N-7491, Trondheim, Norway.
| | - Halfdan Petursson
- General Practice Research Unit, Department of Public Health and Nursing, NTNU, Norwegian University of Science and Technology, PO Box 8905 MTFS, N-7491, Trondheim, Norway.,Research and Development Primary Health Care, Research and Development Center Gothenburg and Södra Bohuslän, Region Västra Götaland, Sweden
| | - Irene Hetlevik
- General Practice Research Unit, Department of Public Health and Nursing, NTNU, Norwegian University of Science and Technology, PO Box 8905 MTFS, N-7491, Trondheim, Norway
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Battegay EJ, Cheetham M. Choosing Wisely – An international and multimorbid perspective. ZEITSCHRIFT FÜR EVIDENZ, FORTBILDUNG UND QUALITÄT IM GESUNDHEITSWESEN 2017. [DOI: 10.1016/j.zefq.2017.10.010
expr 864712450 + 941336122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
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Battegay EJ, Cheetham M. Choosing Wisely - An international and multimorbid perspective. ZEITSCHRIFT FUR EVIDENZ FORTBILDUNG UND QUALITAET IM GESUNDHEITSWESEN 2017; 129:27-30. [PMID: 29153351 DOI: 10.1016/j.zefq.2017.10.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Some medical diagnostic and therapeutic interventions are non-beneficial or even harmful. The Choosing Wisely campaign has encouraged the generation of "top five" lists of unnecessary low-value services in different specialist areas. In the USA alone, where the campaign was launched, these lists include a total of 450 evidence-based recommendations. Medical scientific societies in further countries such as Canada, Australia, New Zealand, England, Switzerland and Germany have since initiated Choosing Wisely campaigns. Besides implementing top five lists, these aim to change attitudes, expectations and practices in the culture of medicine. The field of internal medicine has initiated change in Switzerland (Swiss Society of General Internal Medicine: Smarter Medicine) and Germany (German Society of Internal Medicine: Klug entscheiden). Formulating Choosing Wisely principles in managing complex patients with multiple concurrent acute or chronic diseases, i. e., multimorbidity (MM), will present a particular challenge. Research is needed to determine the primary sources of overuse in specific combinations of diseases (i. e., MM clusters) and spearhead corresponding recommendations. National Choosing Widely campaigns may serve as a forerunner to a more global initiative.
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Affiliation(s)
- Edouard J Battegay
- Department of Internal Medicine, University Hospital Zurich, Zurich, Switzerland; Center of Competence Multimorbidity, University of Zurich, Zurich, Switzerland; University Research Priority Program "Dynamics of Healthy Aging", University of Zurich, Zurich, Switzerland.
| | - Marcus Cheetham
- Department of Internal Medicine, University Hospital Zurich, Zurich, Switzerland; Center of Competence Multimorbidity, University of Zurich, Zurich, Switzerland; University Research Priority Program "Dynamics of Healthy Aging", University of Zurich, Zurich, Switzerland
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Muche-Borowski C, Lühmann D, Schäfer I, Mundt R, Wagner HO, Scherer M. Development of a meta-algorithm for guiding primary care encounters for patients with multimorbidity using evidence-based and case-based guideline development methodology. BMJ Open 2017; 7:e015478. [PMID: 28645968 PMCID: PMC5734311 DOI: 10.1136/bmjopen-2016-015478] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE The study aimed to develop a comprehensive algorithm (meta-algorithm) for primary care encounters of patients with multimorbidity. We used a novel, case-based and evidence-based procedure to overcome methodological difficulties in guideline development for patients with complex care needs. STUDY DESIGN Systematic guideline development methodology including systematic evidence retrieval (guideline synopses), expert opinions and informal and formal consensus procedures. SETTING Primary care. INTERVENTION The meta-algorithm was developed in six steps:1. Designing 10 case vignettes of patients with multimorbidity (common, epidemiologically confirmed disease patterns and/or particularly challenging health care needs) in a multidisciplinary workshop.2. Based on the main diagnoses, a systematic guideline synopsis of evidence-based and consensus-based clinical practice guidelines was prepared. The recommendations were prioritised according to the clinical and psychosocial characteristics of the case vignettes.3. Case vignettes along with the respective guideline recommendations were validated and specifically commented on by an external panel of practicing general practitioners (GPs).4. Guideline recommendations and experts' opinions were summarised as case specific management recommendations (N-of-one guidelines).5. Healthcare preferences of patients with multimorbidity were elicited from a systematic literature review and supplemented with information from qualitative interviews.6. All N-of-one guidelines were analysed using pattern recognition to identify common decision nodes and care elements. These elements were put together to form a generic meta-algorithm. RESULTS The resulting meta-algorithm reflects the logic of a GP's encounter of a patient with multimorbidity regarding decision-making situations, communication needs and priorities. It can be filled with the complex problems of individual patients and hereby offer guidance to the practitioner. Contrary to simple, symptom-oriented algorithms, the meta-algorithm illustrates a superordinate process that permanently keeps the entire patient in view. CONCLUSION The meta-algorithm represents the back bone of the multimorbidity guideline of the German College of General Practitioners and Family Physicians. This article presents solely the development phase; the meta-algorithm needs to be piloted before it can be implemented.
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Affiliation(s)
- Cathleen Muche-Borowski
- Institute for Primary Care and Family Medicine, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Dagmar Lühmann
- Institute for Primary Care and Family Medicine, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Ingmar Schäfer
- Institute for Primary Care and Family Medicine, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Rebekka Mundt
- Institute for Primary Care and Family Medicine, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Hans-Otto Wagner
- Institute for Primary Care and Family Medicine, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Martin Scherer
- Institute for Primary Care and Family Medicine, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
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8
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Gassmann D, Cheetham M, Siebenhuener K, Holzer BM, Meindl-Fridez C, Hildenbrand FF, Virgini V, Martin M, Battegay E. The multimorbidity interaction severity index (MISI): A proof of concept study. Medicine (Baltimore) 2017; 96:e6144. [PMID: 28225495 PMCID: PMC5569438 DOI: 10.1097/md.0000000000006144] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Therapeutic decision-making for patients with multimorbidity (MM) is challenging. Clinical practice guidelines inadequately address harmful interactions and resulting therapeutic conflicts within and among diseases. A patient-specific measure of MM severity that takes account of this conflict is needed.As a proof of concept, we evaluated whether the new Multimorbidity Interaction Severity Index (MISI) could be used to reliably differentiate patients in terms of lower versus higher potential for harmful interactions.Two hypothetical patient cases were generated, each with 6 concurrent morbidities. One case had a low (i.e., low conflict case) and the other a high (i.e., high conflict case) potential for harmful interactions. All possible interactions between conditions and treatments were extracted from each case's record into a multimorbidity interaction matrix. Experienced general internists (N = 18) judged each interaction in the matrix in terms of likely resource utilization needed to manage the interaction. Based on these judgements, a composite index of MM interaction severity, that is, the MISI, was generated for each physician and case.The difference between each physician's MISI score for the 2 cases (MISIdiff) was computed. Based on MISIdiff, the high conflict case was judged to be of significantly greater MM severity than was the low conflict case. The positive values of the inter-quartile range, a measure of variation (or disagreement) between the 2 cases, indicated general consistency of individual physicians in judging MM severity.The data indicate that the MISI can be used to reliably differentiate hypothetical multimorbid patients in terms of lesser versus greater severity of potentially harmful interactive effects. On this basis, the MISI will be further developed for use in patient-specific assessment and management of MM. The clinical relevance of the MISI as an alternative approach to defining MM severity is discussed.
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Affiliation(s)
- Dimitri Gassmann
- Department of Internal Medicine, University Hospital Zurich
- Center of Competence Multimorbidity
| | - Marcus Cheetham
- Department of Internal Medicine, University Hospital Zurich
- Center of Competence Multimorbidity
- University Research Priority Program “Dynamics of Healthy Aging,” University of Zurich
| | - Klarissa Siebenhuener
- Department of Internal Medicine, University Hospital Zurich
- Center of Competence Multimorbidity
| | - Barbara M. Holzer
- Department of Internal Medicine, University Hospital Zurich
- Center of Competence Multimorbidity
| | - Claudine Meindl-Fridez
- Department of Internal Medicine, University Hospital Zurich
- Center of Competence Multimorbidity
| | - Florian F. Hildenbrand
- Department of Internal Medicine, University Hospital Zurich
- Center of Competence Multimorbidity
| | | | - Mike Martin
- Center of Competence Multimorbidity
- University Research Priority Program “Dynamics of Healthy Aging,” University of Zurich
- Division of Gerontopsychology and Gerontology, Department of Psychology, University of Zurich, Zurich, Switzerland
| | - Edouard Battegay
- Department of Internal Medicine, University Hospital Zurich
- Center of Competence Multimorbidity
- University Research Priority Program “Dynamics of Healthy Aging,” University of Zurich
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Violán C, Foguet-Boreu Q, Roso-Llorach A, Rodriguez-Blanco T, Pons-Vigués M, Pujol-Ribera E, Valderas JM. [Multimorbidity patterns in young adults in Catalonia: an analysis of clusters]. Aten Primaria 2016; 48:479-92. [PMID: 26706180 PMCID: PMC6877846 DOI: 10.1016/j.aprim.2015.10.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 10/01/2015] [Accepted: 10/17/2015] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE The aim of this study was to identify multimorbidity patterns in patients from 19 to 44 years attended in primary care in Catalonia in 2010. DESIGN Cross-sectional study. SETTING 251 primary care centres. PARTICIPANTS 530,798 people with multimorbidity, aged 19 to 44 years. MAIN OUTCOME MEASURES Multimorbidity was defined as the coexistence of ≥2 more International Classification system (ICD-10) registered in the electronic health record. Multimorbidity patterns were identified using hierarchical cluster analysis and by sex and age group (19-24 and 25-44). RESULTS Of the 882,708 people from initial population, 530,798 (60.1%) accomplished multimorbidity criterion. Mean age was 33.0 years (SD: 7.0) and 53.3% were women. Multimorbidity was higher in the 25-to 44-years-old group with respect the younger group (60.5 vs. 58.1%, p<0.001), being higher in women. Most prevalent cluster in all groups included, among others, by dental caries, smoking, dorsalgia, common cold and other anxiety disorders. For both sexes in the 25-to 44-years-old group appeared the cardiovascular-endocrine-metabolic pattern (obesity, lipid disorders and arterial hypertension). CONCLUSIONS Multimorbidity affects more than half of persons between 19 to 44-years-old. The most prevalent cluster is formed by grouping common diseases (dental caries, common cold, smoking, anxiety disorders and dorsalgias). Another pattern to highlight is the cardiovascular-endocrine-metabolic pattern in the 25- to 44 years-old group. Knowledge of patterns of multimorbidity in young adults could be used to design individualized preventive strategies.
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Affiliation(s)
- Concepción Violán
- Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, España; Universitat Autònoma de Barcelona, Bellaterra, Cerdanyola del Vallès, España; Institut Català de la Salut, Cataluña, España.
| | - Quintí Foguet-Boreu
- Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, España; Universitat Autònoma de Barcelona, Bellaterra, Cerdanyola del Vallès, España; Hospital de Campdevànol, Campdevànol, España
| | - Albert Roso-Llorach
- Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, España; Universitat Autònoma de Barcelona, Bellaterra, Cerdanyola del Vallès, España
| | - Teresa Rodriguez-Blanco
- Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, España; Universitat Autònoma de Barcelona, Bellaterra, Cerdanyola del Vallès, España
| | - Mariona Pons-Vigués
- Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, España; Universitat Autònoma de Barcelona, Bellaterra, Cerdanyola del Vallès, España
| | - Enriqueta Pujol-Ribera
- Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, España; Universitat Autònoma de Barcelona, Bellaterra, Cerdanyola del Vallès, España; Institut Català de la Salut, Cataluña, España
| | - Jose M Valderas
- Health Services & Policy Research Group, School of Medicine, University of Exeter, Exeter, EX1 2LU, Gran Bretaña
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Austad B, Hetlevik I, Mjølstad BP, Helvik AS. Applying clinical guidelines in general practice: a qualitative study of potential complications. BMC FAMILY PRACTICE 2016; 17:92. [PMID: 27449959 PMCID: PMC4957916 DOI: 10.1186/s12875-016-0490-3] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 07/13/2016] [Indexed: 11/24/2022]
Abstract
Background Clinical guidelines for single diseases often pose problems in general practice work with multimorbid patients. However, little research focuses on how general practice is affected by the demand to follow multiple guidelines. This study explored Norwegian general practitioners’ (GPs’) experiences with and reflections upon the consequences for general practice of applying multiple guidelines. Methods Qualitative focus group study carried out in Mid-Norway. The study involved a purposeful sample of 25 Norwegian GPs from four pre-existing groups. Interviews were audio-recorded, transcribed and analyzed using systematic text condensation, i.e. applying a phenomenological approach. Results The GPs’ responses clustered around two major topics: 1) Complications for the GPs of applying multiple guidelines; and, 2) Complications for their patients when GPs apply multiple guidelines. For the GPs, applying multiple guidelines created a highly problematic situation as they felt obliged to implement guidelines that were not suited to their patients: too often, the map and the terrain did not match. They also experienced greater insecurity regarding their own practice which, they admitted, resulted in an increased tendency to practice ‘defensive medicine’. For their patients, the GPs experienced that applying multiple guidelines increased the risk of polypharmacy, excessive non-pharmacological recommendations, a tendency toward medicalization and, for some, a reduction in quality of life. Conclusions The GPs experienced negative consequences when obliged to apply a variety of single disease guidelines to multimorbid patients, including increased risk of polypharmacy and overtreatment. We believe patient-centered care and the GPs’ courage to non-comply when necessary may aid in reducing these risks. Health care authorities and guideline developers need to be aware of the potential negative effects of applying a single disease focus in general practice, where multimorbidity is highly prevalent.
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Affiliation(s)
- Bjarne Austad
- Sjøsiden Medical Centre, Trondheim, Norway. .,General Practice Research Unit, Department of Public Health and General Practice, NTNU, Norwegian University of Science and Technology, PO Box 8905, MTFS, 7491, Trondheim, Norway.
| | - Irene Hetlevik
- General Practice Research Unit, Department of Public Health and General Practice, NTNU, Norwegian University of Science and Technology, PO Box 8905, MTFS, 7491, Trondheim, Norway
| | - Bente Prytz Mjølstad
- General Practice Research Unit, Department of Public Health and General Practice, NTNU, Norwegian University of Science and Technology, PO Box 8905, MTFS, 7491, Trondheim, Norway.,Saksvik Medical Centre, Hundhamaren, Norway
| | - Anne-Sofie Helvik
- General Practice Research Unit, Department of Public Health and General Practice, NTNU, Norwegian University of Science and Technology, PO Box 8905, MTFS, 7491, Trondheim, Norway.,Department of Ear, Nose and Throat, Head and Neck Surgery, Trondheim University Hospital, Trondheim, Norway
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Scherer M, Hansen H, Gensichen J, Mergenthal K, Riedel-Heller S, Weyerer S, Maier W, Fuchs A, Bickel H, Schön G, Wiese B, König HH, van den Bussche H, Schäfer I. Association between multimorbidity patterns and chronic pain in elderly primary care patients: a cross-sectional observational study. BMC FAMILY PRACTICE 2016; 17:68. [PMID: 27267905 PMCID: PMC4895952 DOI: 10.1186/s12875-016-0468-1] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 05/27/2016] [Indexed: 01/28/2023]
Abstract
BACKGROUND Multimorbidity is a highly prevalent health problem, which may reduce adherence, produce conflicts in treatment, and is not yet supported by evidence-based clinical recommendations. Many older people suffer from more than one chronic disease as well as from chronic pain. There is some evidence that disease management can become more complex if multimorbid patients suffer from chronic pain. In order to better consider the patients' comorbidity spectrum in clinical pain treatment recommendations, evidence is needed regarding which disease combinations are frequently related with the presence of chronic pain. Therefore, our aim is to identify diseases and disease combinations in a multimorbid population, which are associated with the patient-reported presence of chronic pain. METHODS Analyses are based on cross-sectional data of the MultiCare Cohort Study, an observational cohort study based on interviews with 3189 multimorbid patients aged 65+, randomly selected from 158 practices, and their GPs. The response rate was 46.2 %. Data were collected in GP interviews and comprehensive patient interviews. Diseases and disease combinations associated with chronic pain were identified by CART (classification and regression tree) analyses performed separately for both genders. 46 chronic conditions were used as predictor variables and a dichotomized score from the Graded Chronic Pain Scale was used as outcome variable. RESULTS About 60 % of the study participants were female. Women more often reported chronic pain than men. The most important predictor of a higher pain level in the female population was chronic low back problems, especially if combined with chronic gastritis, hyperuricemia/gout, cardiac insufficiency, neuropathies or depression. Regarding the pain level the male population was also divided best by chronic low back problems, especially if combined with intestinal diverticulosis, neuropathies or chronic ischemic heart disease. CONCLUSIONS Our analyses are a first step in identifying diseases and disease combinations that are related to chronic pain. The most important condition seems to be low back problems. Back pain and pain in other body regions seems to be interrelated with cardiometabolic conditions. In women, psychosocial issues like depression also seem to be relevant. TRIAL REGISTRATION ISRCTN89818205 .
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Affiliation(s)
- Martin Scherer
- Department of Primary Medical Care, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Heike Hansen
- Department of Primary Medical Care, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jochen Gensichen
- Institute of General Practice, University of Jena, Jena, Germany
| | - Karola Mergenthal
- Institute of General Practice, University of Frankfurt am Main, Frankfurt am Main, Germany
| | - Steffi Riedel-Heller
- Institute for Social Medicine, Occupational Health and Public Health, University of Leipzig, Leipzig, Germany
| | - Siegfried Weyerer
- Central Institute of Mental Health, University of Heidelberg, Mannheim, Germany
| | - Wolfgang Maier
- Department of Psychiatry and Psychotherapy, University of Bonn, Bonn, Germany
| | - Angela Fuchs
- Institute of General Practice, University of Düsseldorf, Düsseldorf, Germany
| | - Horst Bickel
- Department of Psychiatry and Psychotherapy, Technical University of Munich, Munich, Germany
| | - Gerhard Schön
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Birgitt Wiese
- Institute for General Practice, Hannover Medical School, Hannover, Germany
| | - Hans-Helmut König
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hendrik van den Bussche
- Department of Primary Medical Care, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ingmar Schäfer
- Department of Primary Medical Care, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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Baker TA, Roker R, Collins HR, Johnson-Lawrence V, Thorpe RJ, Mingo CA, Vasquez E. Beyond Race and Gender: Measuring Behavioral and Social Indicators of Pain Treatment Satisfaction in Older Black and White Cancer Patients. Gerontol Geriatr Med 2016; 2:2333721415625688. [PMID: 28138486 PMCID: PMC5119862 DOI: 10.1177/2333721415625688] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Revised: 12/10/2015] [Accepted: 12/14/2015] [Indexed: 11/16/2022] Open
Abstract
There are a number of factors that influence compliance with prescribed plans of care. However, there remains a need to identify the collective source health, behavioral, and social constructs have on treatment satisfaction. This study aimed to identify indicators of pain treatment satisfaction among older adults receiving outpatient treatment from a comprehensive cancer center in the southeast region of the United States. Data included a sample of 149 Black and White patients diagnosed with cancer, with the majority being White (85%) and female (57%). Patients were surveyed on questions assessing pain treatment satisfaction, pain severity, and additional social characteristics. A series of multivariate models were specified, whereby patients reporting multiple chronic conditions, poor communication, and perceived discrimination were less satisfied with treatment. Positive communication, higher self-efficacy, and fewer perceived discriminatory acts were significant among the female patients only. These findings suggest the need to develop clinical models that assess how these factors influence the degree of treatment satisfaction, while providing a comprehensive mechanism by which to service the long-term needs of older adults.
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Foguet-Boreu Q, Violán C, Rodriguez-Blanco T, Roso-Llorach A, Pons-Vigués M, Pujol-Ribera E, Cossio Gil Y, Valderas JM. Multimorbidity Patterns in Elderly Primary Health Care Patients in a South Mediterranean European Region: A Cluster Analysis. PLoS One 2015; 10:e0141155. [PMID: 26524599 PMCID: PMC4629893 DOI: 10.1371/journal.pone.0141155] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Accepted: 10/04/2015] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE The purpose of this study was to identify clusters of diagnoses in elderly patients with multimorbidity, attended in primary care. DESIGN Cross-sectional study. SETTING 251 primary care centres in Catalonia, Spain. PARTICIPANTS Individuals older than 64 years registered with participating practices. MAIN OUTCOME MEASURES Multimorbidity, defined as the coexistence of 2 or more ICD-10 disease categories in the electronic health record. Using hierarchical cluster analysis, multimorbidity clusters were identified by sex and age group (65-79 and ≥80 years). RESULTS 322,328 patients with multimorbidity were included in the analysis (mean age, 75.4 years [Standard deviation, SD: 7.4], 57.4% women; mean of 7.9 diagnoses [SD: 3.9]). For both men and women, the first cluster in both age groups included the same two diagnoses: Hypertensive diseases and Metabolic disorders. The second cluster contained three diagnoses of the musculoskeletal system in the 65- to 79-year-old group, and five diseases coincided in the ≥80 age group: varicose veins of the lower limbs, senile cataract, dorsalgia, functional intestinal disorders and shoulder lesions. The greatest overlap (54.5%) between the three most common diagnoses was observed in women aged 65-79 years. CONCLUSION This cluster analysis of elderly primary care patients with multimorbidity, revealed a single cluster of circulatory-metabolic diseases that were the most prevalent in both age groups and sex, and a cluster of second-most prevalent diagnoses that included musculoskeletal diseases. Clusters unknown to date have been identified. The clusters identified should be considered when developing clinical guidance for this population.
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Affiliation(s)
- Quintí Foguet-Boreu
- Institut Universitari d’Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol). Universitat Autònoma de Barcelona, Gran Via Corts Catalanes, 587 àtic, Barcelona, Spain
- University of Girona, Carrer Emili Grahit, 77, Girona, Catalonia, Spain
- * E-mail:
| | - Concepción Violán
- Institut Universitari d’Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol). Universitat Autònoma de Barcelona, Gran Via Corts Catalanes, 587 àtic, Barcelona, Spain
| | - Teresa Rodriguez-Blanco
- Institut Universitari d’Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol). Universitat Autònoma de Barcelona, Gran Via Corts Catalanes, 587 àtic, Barcelona, Spain
| | - Albert Roso-Llorach
- Institut Universitari d’Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol). Universitat Autònoma de Barcelona, Gran Via Corts Catalanes, 587 àtic, Barcelona, Spain
| | - Mariona Pons-Vigués
- Institut Universitari d’Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol). Universitat Autònoma de Barcelona, Gran Via Corts Catalanes, 587 àtic, Barcelona, Spain
- University of Girona, Carrer Emili Grahit, 77, Girona, Catalonia, Spain
| | - Enriqueta Pujol-Ribera
- Institut Universitari d’Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol). Universitat Autònoma de Barcelona, Gran Via Corts Catalanes, 587 àtic, Barcelona, Spain
- University of Girona, Carrer Emili Grahit, 77, Girona, Catalonia, Spain
| | - Yolima Cossio Gil
- Institut Universitari d’Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol). Universitat Autònoma de Barcelona, Gran Via Corts Catalanes, 587 àtic, Barcelona, Spain
| | - Jose M. Valderas
- Health Services & Policy Research Group, School of Medicine, University of Exeter, Exeter, United Kingdom
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Aging and Multimorbidity: New Tasks, Priorities, and Frontiers for Integrated Gerontological and Clinical Research. J Am Med Dir Assoc 2015; 16:640-7. [PMID: 25958334 DOI: 10.1016/j.jamda.2015.03.013] [Citation(s) in RCA: 299] [Impact Index Per Article: 33.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 03/10/2015] [Indexed: 12/21/2022]
Abstract
Aging is characterized by rising susceptibility to development of multiple chronic diseases and, therefore, represents the major risk factor for multimorbidity. From a gerontological perspective, the progressive accumulation of multiple diseases, which significantly accelerates at older ages, is a milestone for progressive loss of resilience and age-related multisystem homeostatic dysregulation. Because it is most likely that the same mechanisms that drive aging also drive multiple age-related chronic diseases, addressing those mechanisms may reduce the development of multimorbidity. According to this vision, studying multimorbidity may help to understand the biology of aging and, at the same time, understanding the underpinnings of aging may help to develop strategies to prevent or delay the burden of multimorbidity. As a consequence, we believe that it is time to build connections and dialogue between the clinical experience of general practitioners and geriatricians and the scientists who study aging, so as to stimulate innovative research projects to improve the management and the treatment of older patients with multiple morbidities.
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Muth C, Kirchner H, van den Akker M, Scherer M, Glasziou PP. Current guidelines poorly address multimorbidity: pilot of the interaction matrix method. J Clin Epidemiol 2014; 67:1242-50. [DOI: 10.1016/j.jclinepi.2014.07.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2013] [Revised: 06/25/2014] [Accepted: 07/12/2014] [Indexed: 10/24/2022]
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Violán C, Foguet-Boreu Q, Roso-Llorach A, Rodriguez-Blanco T, Pons-Vigués M, Pujol-Ribera E, Muñoz-Pérez MÁ, Valderas JM. Burden of multimorbidity, socioeconomic status and use of health services across stages of life in urban areas: a cross-sectional study. BMC Public Health 2014; 14:530. [PMID: 24885174 PMCID: PMC4060853 DOI: 10.1186/1471-2458-14-530] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Accepted: 05/15/2014] [Indexed: 11/10/2022] Open
Abstract
Background The burden of chronic conditions and multimorbidity is a growing health problem in developed countries. The study aimed to determine the estimated prevalence and patterns of multimorbidity in urban areas of Catalonia, stratified by sex and adult age groups, and to assess whether socioeconomic status and use of primary health care services were associated with multimorbidity. Methods A cross-sectional study was conducted in Catalonia. Participants were adults (19+ years) living in urban areas, assigned to 251 primary care teams. Main outcome: multimorbidity (≥2 chronic conditions). Other variables: sex (male/female), age (19–24; 25–44; 45–64; 65–79; 80+ years), socioeconomic status (quintiles), number of health care visits during the study. Results We included 1,356,761 patients; mean age, 47.4 years (SD: 17.8), 51.0% women. Multimorbidity was present in 47.6% (95% CI 47.5-47.7) of the sample, increasing with age in both sexes but significantly higher in women (53.3%) than in men (41.7%). Prevalence of multimorbidity in each quintile of the deprivation index was higher in women than in men (except oldest group). In women, multimorbidity prevalence increased with quintile of the deprivation index. Overall, the median (interquartile range) number of primary care visits was 8 (4–14) in multimorbidity vs 1 (0–4) in non-multimorbidity patients. The most prevalent multimorbidity pattern beyond 45 years of age was uncomplicated hypertension and lipid disorder. Compared with the least deprived group, women in other quintiles of the deprivation index were more likely to have multimorbidity than men until 65 years of age. The odds of multimorbidity increased with number of visits in all strata. Conclusions When all chronic conditions were included in the analysis, almost 50% of the adult urban population had multimorbidity. The prevalence of multimorbidity differed by sex, age group and socioeconomic status. Multimorbidity patterns varied by life-stage and sex; however, circulatory-endocrine-metabolic patterns were the most prevalent multimorbidity pattern after 45 years of age. Women younger than 80 years had greater prevalence of multimorbidity than men, and women’s multimorbidity prevalence increased as socioeconomic status declined in all age groups. Identifying multimorbidity patterns associated with specific age-related life-stages allows health systems to prioritize and to adapt clinical management efforts by age group.
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Affiliation(s)
- Concepción Violán
- Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain.
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Blozik E, Dubben HH, Wagner HO, Scherer M. [Comorbidity in medical guidelines: comparison of the current state, epidemiologic models and expert opinion]. ZEITSCHRIFT FUR EVIDENZ FORTBILDUNG UND QUALITAET IM GESUNDHEITSWESEN 2014; 108:219-28. [PMID: 24889711 DOI: 10.1016/j.zefq.2014.02.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Revised: 01/27/2014] [Accepted: 02/03/2014] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Medical guidelines focusing on monomorbidities can be associated with adverse events in multimorbid patients. This study investigates how comorbidities are actually particularised in a set of German guidelines. In addition, it evaluates whether two epidemiologic approaches (disease combinations or clusters of comorbidities) can be used to systematically integrate multimorbidity in guideline development. METHODS Based on a matrix of 30 comorbidities, mentioning of comorbidities in 8 current German guidelines (diabetes mellitus, hypertension, heart failure, coronary heart disease, chronic obstructive lung disease/asthma, coxarthrosis, low back pain, osteoporosis) was investigated. These so called index diseases were selected on the basis of the hypothetical case of a multimorbid patient published by Cynthia Boyd and colleagues in 2005. Mentioning of comorbidities in the guidelines was compared to the epidemiologic approaches of disease combinations and clusters of comorbidities. In addition, using the comorbidity matrix, 36 physicians involved in everyday care of multimorbid patients assessed whether an explicit recommendation for the listed comorbidities would be helpful. RESULTS Mentioning of comorbidities was very heterogeneous across the guidelines investigated, ranging from 0 to more than 10. The proportion of the comorbidities that were considered relevant by the survey participants ranged from 0 % to 62 % with a focus on cardiovascular and metabolic diseases. When using disease combinations, only 0 to 3 of the "relevant" comorbidities were identified. Using the cluster model may be helpful in identifying whether a particular comorbidity is thematically close to the index disease or whether it is associated with an interacting thematic area. CONCLUSIONS Methodological support is needed for addressing comorbidities in guidelines in a more consistent way. The currently existing epidemiologic approaches should not be used in their current form without being further developed and re-evaluated. Expert opinion of physicians involved in the care of multimorbid patients should be systematically included in methodological refinement studies.
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Affiliation(s)
- Eva Blozik
- Institut für Allgemeinmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg.
| | - Hans-Hermann Dubben
- Institut für Allgemeinmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg
| | - Hans-Otto Wagner
- Institut für Allgemeinmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg
| | - Martin Scherer
- Institut für Allgemeinmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg
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