"It's a toss up between my hearing, my heart, and my hip": prioritizing and accommodating multiple morbidities by vulnerable older adults

Allergen-specific immunotherapy at the extremes of age: below 5 years and elderly: evidence beyond indications?

PURPOSE OF REVIEW

Allergen-specific immunotherapy (AIT) has been used in clinical practice to treat allergic diseases for over 100 years. The effectiveness and safety of AIT have been substantiated in numerous studies; however, children before 5 years of age and elderly are not encompassed generally. This review aims to present the current understanding of AIT in the extremes of age.

RECENT FINDINGS

Early allergen immunotherapy during infancy or early childhood may prevent the development of allergic sensitization to common allergens, thereby reducing the risk of developing allergic diseases later in life. In the elderly, improved symptoms and quality of life and reduced dependence on medication are indicated the importance on the implementation of AIT. Both clinical and immunological parameters demonstrated that the treatment was effective at the time of cessation and trend to sustained tolerance.

SUMMARY

There is no specific lower or upper age limit for initiating immunotherapy; however, it is important to thoroughly evaluate the severity of disease and the risks and benefits in each case.

Concurrent Medication Adherence in Hypertensive Patients With High-Risk Comorbidities

BACKGROUND

Hypertensive patients with high-risk comorbidities require medications for each condition, leading to greater burden. The number of chronic conditions can affect patients' concurrent medication adherence.

OBJECTIVE

We aimed to compare the characteristics of groups based on their concurrent medication adherence and investigate the association between the number of high-risk comorbidities and concurrent medication adherence for patients with hypertension and high-risk comorbidities.

METHODS

A secondary data analysis was performed with the 2018 Korea Health Panel Survey, including 2230 patients with hypertension and at least 1 high-risk comorbidity who were prescribed medications for at least 2 conditions. Using medication adherence for each condition, we identified 3 concurrent medication adherence groups: adherent, suboptimal, and nonadherent groups. Multinominal logistic regression was used to determine the association between the number of high-risk comorbidities and the concurrent medication adherence groups.

RESULTS

Adherent, suboptimal, and nonadherent groups included 85%, 11%, and 4% of the patients, respectively. Whereas having more high-risk comorbidities was associated with belonging to the suboptimal group compared with the adherent group (adjusted odds ratio, 1.46), having fewer high-risk comorbidities was associated with belonging to the nonadherent group compared with the adherent group (adjusted odds ratio, 0.52).

CONCLUSIONS

We identified 3 groups based on their concurrent medication adherence. Our results indicated that the relationship of the number of high-risk comorbidities with the concurrent medication adherence group was inconsistent.

Symptom burden and quality of life among patient and family caregiver dyads in advanced cancer

PURPOSE

Symptom management among patients diagnosed with advanced cancer is a high priority in clinical care that often involves the support of a family caregiver. However, limited studies have examined parallel patient and caregiver symptom burden and associations with their own and each other's quality of life (QOL). This study seeks to identify patient and caregiver symptom clusters and investigate associations between identified clusters and demographic, clinical, and psychosocial factors (cognitive appraisals and QOL).

METHODS

This study was a secondary analysis of self-reported baseline survey data collected from a randomized clinical trial of 484 adult advanced cancer patients and their caregivers. Latent class analysis and factor analysis were used to identify symptom clusters. Bivariate statistics tested associations between symptom clusters and demographic, clinical, and psychosocial variables.

RESULTS

The most prevalent symptom for patients was energy loss/fatigue and for caregivers, mental distress. Low, moderate, and high symptom burden subgroups were identified at the patient, caregiver, and dyad level. Age, gender, race, income, chronic conditions, cancer type, and treatment type were associated with symptom burden subgroups. Higher symptom burden was associated with more negative appraisals of the cancer and caregiving experience, and poorer QOL (physical, social, emotional, functional, and overall QOL). Dyads whose caregivers had more chronic conditions were more likely to be in the high symptom burden subgroup.

CONCLUSION

Patient and caregiver symptom burden influence their own and each other's QOL. These findings reinforce the need to approach symptom management from a dyadic perspective.

Experiences and challenges of people living with multiple long-term conditions in managing their care in primary care settings in Kerala, India: A qualitative study

BACKGROUND

Multimorbidity or multiple long-term conditions (MLTCs), the coexistence of two or more chronic conditions within an individual, presents a growing concern for healthcare systems and individuals' well-being. However, we know little about the experiences of those living with MLTCs in low- and middle-income countries (LMICs) such as India. We explore how people living with MLTCs describe their illness, their engagements with healthcare services, and challenges they face within primary care settings in Kerala, India.

METHODS

We designed a qualitative descriptive study and conducted in-depth, semi-structured interviews with 31 people (16 males and 15 females) from family health centres (FHCs) in Kerala. Interview data were recorded, transcribed, and thematic analysis using the Framework Method was undertaken.

FINDINGS

Two main themes and three sub-themes each were identified; (1) Illness impacts on life (a)physical issues (b) psychological difficulties (c) challenges of self-management and (2) Care-coordination maze (a)fragmentation and poor continuity of care (b) medication management; an uphill battle and (c) primary care falling short. All participants reported physical and psychological challenges associated with their MLTCs. Younger participants reported difficulties in their professional lives, while older participants found household activities challenging. Emotional struggles encompassed feelings of hopelessness and fear rooted in concerns about chronic illness and physical limitations. Older participants, adhering to Kerala's familial support norms, often found themselves emotionally distressed by the notion of burdening their children. Challenges in self-management, such as dietary restrictions, medication adherence, and physical activity engagement, were common. The study highlighted difficulties in coordinating care, primarily related to traveling to multiple healthcare facilities, and patients' perceptions of FHCs as fit for diabetes and hypertension management rather than their multiple conditions. Additionally, participants struggled to manage the task of remembering and consistently taking multiple medications, which was compounded by confusion and memory-related issues.

CONCLUSION

This study offers an in-depth view of the experiences of individuals living with MLTCs from Kerala, India. It emphasizes the need for tailored and patient-centred approaches that enhance continuity and coordination of care to manage complex MLTCs in India and similar LMICs.

Older adults using social support to improve self-care (OASIS): Adaptation, implementation and feasibility of peer support for older adults with T2D in appalachia: A feasibility study protocol

INTRODUCTION

The prevalence of type 2 diabetes (T2D) is 17% higher in rural dwellers compared to their urban counterparts, and it increases with age, with an estimated 25% of older adults (≥ 65 years) diagnosed. Appropriate self-care is necessary for optimal clinical outcomes. Overall, T2D self-care is consistently poor among the general population but is even worse in rural-dwellers and older adults. In rural Kentucky, up to 23% of adults in Appalachian communities have been diagnosed with T2D and, of those, 26.8% are older adults. To attain optimal clinical outcomes, social environmental factors, including social support, are vital when promoting T2D self-care. Specifically, peer support has shown to be efficacious in improving T2D self-care behaviors and clinical and psychosocial outcomes related to T2D; however, literature also suggests self-selected social support can be obstructive when engaging in healthful activities. Currently available evidence-based interventions (EBIs) using peer support have not been used to prioritize older adults, especially those living in rural communities.

METHOD

To address this gap, we conducted formative research with stakeholders, and collaboratively identified an acceptable and feasible peer support EBI-peer health coaching (PHC)-that has resulted in improved clinical and psychosocial T2D-related outcomes among participants who did not reside in rural communities nor were ≥65 years. The goal of the proposed study is to use a 2x2 factorial design to test the adapted PHC components and determine their preliminary effectiveness to promote self-care behaviors and improve glycemic control among older adults living in Appalachian Kentucky. Testing the PHC components of the peer support intervention will be instrumental in promoting care for older adults in Appalachia, as it will allow for a larger scale intervention, which if effective, could be disseminated to community partners in Appalachia.

TRIAL REGISTRATION

This study was registered at www.clinicaltrials.gov (NCT06003634) in August 2023.

Above and Beyond Number of Illnesses: A Two-Sample Replication of Current Approaches to Depressive Symptoms in Multimorbidity

OBJECTIVES

To expand current models of depressive symptoms in older adults with multimorbidity (MM) beyond the number of illnesses as a predictor of worsened mental health.

METHODS

Two-sample replication study of adults ≥62 years old with ≥ two chronic illnesses, who completed validated questionnaires assessing depressive symptoms, and disease- and treatment-related stressors. Data were analyzed using hierarchical linear regression.

RESULTS

The model of cumulative number of illnesses was worse at explaining variance in depressive symptoms (Sample 1 R2 = .035; Sample 2 R2 = .029), compared to models including disease- and treatment-related stressors (Sample 1 R2 = .37; Sample 2 R2 = .47). Disease-related stressors were the strongest factor associated with depressive symptoms, specifically, poor subjective cognitive function (Sample 1: b = -.202, p = .013; Sample 2: b = -.288, p < .001) and greater somatic symptoms (b = .455, p < .001; Sample 2: b = .355, p < .001).

CONCLUSIONS

Using the number of illnesses to understand depressive symptoms in MM is a limited approach. Models that move beyond descriptive relationships between MM and depressive symptoms are needed.

CLINICAL IMPLICATIONS

Providers should consider the role of somatic symptom management in patients with MM and depressive symptoms.

Managing Complexity: Black Older Adults With Multimorbidity

BACKGROUND AND OBJECTIVES

Black older adults have higher rates of multimorbidity and receive less effective multimorbidity support than their white counterparts. Yet little is known about the experiences of Black older adults with multimorbidity that may be at the heart of those disparities and which are central to interventions and improving care for this population. In this study, we aimed to conceptualize the multimorbidity management (MM) experience for Black older adults.

RESEARCH DESIGN AND METHODS

As part of a larger study on Black older adults' multimorbidity and physician empathy, we conducted in-depth qualitative interviews with 30 Black older adults living in a large midwestern city in the United States aged 65 years and older with self-reported multimorbidity. We used grounded theory analysis to distill findings into a core conceptual category as well as component domains and dimensions.

RESULTS

"Managing complexity" emerged as the core category to describe MM in our sample. Managing complexity included domains of "social context," "daily logistics," "care time," and "care roles."

DISCUSSION AND IMPLICATIONS

We discuss how managing complexity is distinct from patient complexity and how it is related to cumulative inequality and precarity. Study findings have potential implications for intervention around provider education and empathy as well as for enabling agency of Black older adults with MM.

Multicomponent telerehabilitation programme for older veterans with multimorbidity: a programme evaluation

INTRODUCTION

Older veterans with multimorbidity experience physical, mental and social factors which may negatively impact health and healthcare access. Physical function, behaviour change skills and loneliness may not be addressed during traditional physical rehabilitation. Thus, a multicomponent telerehabilitation programme could address these unmet needs. This programme evaluation assessed the safety, feasibility and change in patient outcomes for a multicomponent telerehabilitation programme.

METHODS

Individuals were eligible if they were a veteran/spouse, age ≥50 years and had ≥3 comorbidities. The telerehabilitation programme included four core components: (1) High-intensity rehabilitation, (2) Coaching interventions, (3) Social support and (4) Technology. Physical therapists delivered the 12-week programme and collected patient outcomes at baseline, 4 weeks, 8 weeks and 12 weeks. Programme evaluation measures included safety events (occurrence and type), feasibility (adherence) and patient outcomes (physical function). Safety and feasibility outcomes were analysed using descriptive statistics. The mean pre-post programme difference and 95% CI for patient outcomes were generated using paired t-tests.

RESULTS

Twenty-one participants enrolled in the telerehabilitation programme; most were male (81%), white (72%) and non-Hispanic (76%), with an average of 5.7 (3.0) comorbidities. Prevalence of insession safety events was 3.2% (0.03 events/session). Fifteen (71.4%) participants adhered to the programme (attended ≥80% of sessions). Mean (95% CI) improvements for physical function are as follows: 4.7 (2.4 to 7.0) repetitions for 30 s sit to stand, 6.0 (4.0 to 9.0) and 5.0 (2.0 to 9.0) repetitions for right arm curl and left arm curl, respectively, and 31.8 (15.9 to 47.7) repetitions for the 2 min step test.

CONCLUSION

The telerehabilitation programme was safe, feasible and demonstrated preprogramme to postprogramme improvements in physical function measures while addressing unmet needs in a vulnerable population. These results support a randomised clinical trial while informing programme and process adaptations.

Self-management of multiple long-term conditions: A systematic review of the barriers and facilitators amongst people experiencing socioeconomic deprivation

BACKGROUND

Multiple long-term conditions are rising across all groups but people experiencing socioeconomic deprivation are found to have a higher prevalence. Self-management strategies are a vital part of healthcare for people with long-term conditions and effective strategies are associated with improved health outcomes in a variety of health conditions. The management of multiple long-term conditions are, however, less effective in people experiencing socioeconomic deprivation, leaving them more at risk of health inequalities. The purpose of this review is to identify and synthesise qualitative evidence on the barriers and facilitators of self-management on long-term conditions in those experiencing socioeconomic deprivation.

METHODS

MEDLINE, EMBASE, AMED, PsycINFO and CINAHL Plus were searched for qualitative studies concerning self-management of multiple long-term conditions among socioeconomically disadvantaged populations. Data were coded and thematically synthesised using NVivo.

FINDINGS

From the search results, 79 relevant qualitative studies were identified after the full text screening and 11 studies were included in the final thematic synthesis. Three overarching analytical themes were identified alongside a set of sub-themes: (1) Challenges of having multiple long-term conditions; prioritisation of conditions, impact of multiple long-term conditions on mental health and wellbeing, polypharmacy, (2) Socioeconomic barriers to self-management; financial, health literacy, compounding impact of multiple long-term conditions and socioeconomic deprivation, (3) Facilitators of self-management in people experiencing socioeconomic deprivation; maintaining independence, 'meaningful' activities, support networks.

DISCUSSION

Self-management of multiple long-term conditions is challenging for people experiencing socioeconomic deprivation due to barriers around financial constraints and health literacy, which can lead to poor mental health and wellbeing. To support targeted interventions, greater awareness is needed among health professionals of the barriers/challenges of self-management among these populations.

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

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

PARTICIPANTS

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

KEY RESULTS

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

CONCLUSIONS

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

[Not Available]

OBJECTIVE

The aim of this study was to identify the health education needs of people suffering from several pathologies including HIV and/or hepatitis, living in vulnerable conditions in Therapeutic Coordination Apartments (known in French as Appartements de Coordination Thérapeutique under the acronym ACT).

METHOD

This article is based on a qualitative and collaborative study involving in research team people living in ACT, professionals of ACT and academics. Interview guides based on the literature were developed. Nine ACTs participated: there were interviews with 36 people with chronic conditions, 9 focus groups with staff members and 9 additional interviews with ACT managers.

RESULTS

Health education needs were identified. These involved: managing one's multiple conditions, managing certain diseases in particular, daily life with multiple chronic conditions, the connections and origins of the diseases. Factors influencing how they deal with one disease rather than another were expressed. The educational needs of people with HIV and/or hepatitis have been highlighted.

CONCLUSION

Health education needs still exist despite the care that people living in ACTs receive. The study makes it possible to put forward proposals for improving support and, more specifically, health education interventions implemented in ACTs: asking additional questions to identify health education needs more precisely, providing polypathology therapeutic patient education (TPE) training to the teams, involving the affected populations, taking into account health literacy levels.

The Association between Multiple Chronic Conditions and Depressive Symptoms: Intersectional Distinctions by Race, Nativity, and Gender

Using random coefficient growth curve analysis, this study utilizes 12 waves of data from the Health and Retirement Study (1994-2016; person-waves = 145,177) to examine the association between multiple chronic conditions (MCC) and depressive symptoms among older adults. Applying cumulative disadvantage and intersectionality theories, we also test whether the association between MCC and depressive symptoms differs by race, nativity, and gender. Findings reveal that MCC prevalence is highest among U.S.-born black women, whereas depressive symptoms are highest among foreign-born Hispanic women. Compared to men, MCC has a stronger effect on women's depressive symptoms. Furthermore, the MCC-depressive symptoms association is strongest for foreign-born Hispanic women. Despite an increase in MCC in the transition from midlife to late life, all race-nativity-gender groups experience a decline in depressive symptoms as they age. The decline in depressive symptoms is steepest for U.S.-born black and foreign-born Hispanic women. Study implications are discussed.

Supporting collaborative reflection on personal values and health

People with multiple chronic conditions (MCC) need support to identify and articulate how their personal values relate to their health. We drew on previous research involving people with MCC to develop three prototypes for supporting reflection on relationships between values and health. We tested these prototypes in a qualitative study involving 12 people with MCC. We identified benefits and limitations to building on patients' existing visit-preparation practices; revealed varying levels of comfort with deep, exploratory reflection involving a facilitator; and found that reflection oriented toward the future could elicit hopeful attitudes and plans for change, while reflection on the past elicited strong resistance. We discuss these findings in relation to previous literature on designing for reflection in three areas: shifting between self-guided and facilitator-guided reflection, balancing between outcome-oriented and exploratory reflection, and exploring temporality in reflection.

Barriers and facilitators to interprofessional collaborative practice for community-dwelling older adults: An integrative review

AIMS AND OBJECTIVES

The aim of this integrative review was to synthesise empirical reports of interprofessional collaborative practice (IPCP) for community-dwelling older adults and uncover barriers and facilitators related to its success as a model of care for this population.

BACKGROUND

IPCP is a model of care that has demonstrated positive outcomes for community-dwelling older adults. However, a summary of barriers and facilitators to IPCP models has not been presented.

METHODS

An integrative review using the method posited by Whittemore and Knafl was completed to identify barriers and facilitators to IPCP for community-dwelling older adults. The literature search was reported following PRISMA guidelines.

RESULTS

Four themes emerged as barriers to IPCP: (1) A (Potential) Logistical Nightmare, (2) All About the Money, (3) If We Can't Test It, Can We Recommend It? and (4) Challenging for the Team, Challenging for the Client. Three themes emerged as facilitators to IPCP: (1) Reducing Resource Waste, (2) The "C" in IPCP and (3) What Matters Most.

CONCLUSIONS

IPCP models for community-dwelling older adults must adapt to the setting of care and client needs. Interprofessional education opportunities for team members facilitate effective IPCP. Healthcare policies and funding structures need to address IPCP for community-dwelling older adults for this model to be successful and sustainable.

RELEVANCE TO CLINICAL PRACTICE

Nurses participate on and lead IPCP teams caring for community-dwelling older adults and, therefore, need to be aware of barriers and facilitators to this model of care.

The attitudes towards, and beliefs about, physical activity in people with osteoarthritis and comorbidity: A qualitative investigation

OBJECTIVE

To investigate the attitudes towards, and beliefs about, physical activity (PA) in older adults with osteoarthritis (OA) and comorbidity to understand experiences and seek ways to improve PA participation.

METHODS

Semi-structured interviews with adults aged ≥45, with self-reported OA and comorbidity (N = 17). Face-to-face interviews explored participant perspectives regarding; (1) attitudes and beliefs about PA in the context of OA and comorbidity and (2) how people with OA and comorbidity could be encouraged to improve and maintain PA levels. Data were transcribed verbatim and inductive thematic analysis was undertaken using a framework approach.

RESULTS

Participants did not conceptualise multiple long-term conditions (LTCs) together and instead self-prioritised OA over other LTCs. Barriers to PA included uncertainty about both the general management of individual LTCs and the effectiveness of PA for their LTCs; and, negative perceptions about their health, ageing and PA. Participants experienced dynamic and co-existing barriers to PA, and problematized this as a multi-level process, identifying a barrier, then a solution, followed by a new barrier. Facilitators of PA included social support and support from knowledgeable healthcare professionals (HCPs), together with PA adapted for OA and comorbidity and daily life. PA levels could be increased through targeted interventions to increase self-efficacy for managing OA alongside other LTCs and self-efficacy for PA.

CONCLUSION

People with OA and comorbidity experience complicated PA barriers. To increase PA levels, tailored PA interventions could include HCP and social support to anticipate and overcome multi-level PA barriers and target increased self-efficacy for LTC management and PA.

The experience of financial burden for people with multimorbidity: A systematic review of qualitative research

Background

Multimorbidity prevalence is increasing globally. People with multimorbidity have higher health care costs, which can create a financial burden.

Objective

To synthesize qualitative research exploring experience of financial burden for people with multimorbidity.

Search strategy

Six databases were searched in May 2019. A grey literature search and backward and forward citation checking were also conducted.

Inclusion criteria

Studies were included if they used a qualitative design, conducted primary data collection, included references to financial burden and had at least one community‐dwelling adult participant with two or more chronic conditions.

Data extraction and synthesis

Screening and critical appraisal were conducted by two reviewers independently. One reviewer extracted data from the results section; this was checked by a second reviewer. GRADE‐CERQual was used to summarize the certainty of the evidence. Data were analysed using thematic synthesis.

Main results

Forty‐six studies from six continents were included. Four themes were generated: the high costs people with multimorbidity experience, the coping strategies they use to manage these costs, and the negative effect of both these on their well‐being. Health insurance and government supports determine the manageability and level of costs experienced.

Discussion

Financial burden has a negative effect on people with multimorbidity. Continuity of care and an awareness of the impact of financial burden of multimorbidity amongst policymakers and health care providers may partially address the issue.

Patient or public contribution

Results were presented to a panel of people with multimorbidity to check whether the language and themes ‘resonated’ with their experiences.

"They are interrelated, one feeds off the other": A taxonomy of perceived disease interactions derived from patients with multiple chronic conditions

OBJECTIVE

To understand patients' experiences with condition interactions and develop a taxonomy to inform care for patients with multiple chronic conditions.

METHODS

We conducted qualitative and quantitative analysis of free-text data from patient surveys in which respondents were asked to indicate their most bothersome chronic condition and describe how their other conditions affect their self-care for that condition. Using standard content analysis, we developed a taxonomy comprising how patients perceive interactions among their conditions, and examined cross-cutting themes that reflect qualities of these interactions.

RESULTS

Among 383 eligible survey respondents, the mean (SD) number of chronic conditions was 4 (2); common conditions included hypertension (60%), chronic pain (49%), arthritis (41%), depression (32%), diabetes (29%), and post-traumatic stress disorder (26%). Patients' perceived condition interactions took four broad forms: 1) unidirectional interactions among conditions and/or treatments, 2) cyclical or multidimensional interactions, 3) uncertain or indistinct interactions, and 4) no perceived interaction. Cross-cutting themes included beliefs about causal relationships between conditions, identification of interactions as negative vs. positive, and interactions between physical and mental health.

CONCLUSION

This study presents a novel taxonomy of condition interactions from the patient perspective.

PRACTICE IMPLICATIONS

Understanding perceived condition interactions may support patient self-management and shared decision-making efforts.

Priorities of patients with multimorbidity and of clinicians regarding treatment and health outcomes: a systematic mixed studies review

OBJECTIVES

To identify studies that have investigated the health outcome and treatment priorities of patients with multimorbidity, clinicians or both, in order to assess whether the priorities of the two groups are in alignment, or whether a disparity exists between the priorities of patients with multimorbidity and clinicians.

DESIGN

Systematic review.

DATA SOURCES

MEDLINE, EMBASE, CINHAL and Cochrane databases from inception to May 2019 using a predefined search strategy, as well as reference lists containing any relevant articles, as per Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Cochrane guidelines.

ELIGIBILITY CRITERIA

We included studies reporting health outcome and treatment priorities of adult patients with multimorbidity, defined as suffering from two or more chronic conditions, or of clinicians in the context of multimorbidity or both. There was no restriction by study design, and studies using quantitative and/or qualitative methodologies were included.

DATA SYNTHESIS

We used a narrative synthesis approach to synthesise the quantitative findings, and a meta-ethnography approach to synthesise the qualitative findings.

RESULTS

Our search identified 24 studies for inclusion, which comprised 12 quantitative studies, 10 qualitative studies and 2 mixed-methods studies. Twelve studies reported the priorities of both patients and clinicians, 10 studies reported the priorities of patients and 2 studies reported the priorities of clinicians alone. Our findings have shown a mostly low level of agreement between the priorities of patients with multimorbidity and clinicians. We found that prioritisation by patients was mainly driven by their illness experiences, while clinicians focused on longer-term risks. Preserving functional ability emerged as a key priority for patients from across our quantitative and qualitative analyses.

CONCLUSION

Recognising that there may be a disparity in prioritisation and understanding the reasons for why this might occur, can facilitate clinicians in accurately eliciting the priorities that are most important to their patients and delivering patient-centred care.

PROSPERO REGISTRATION NUMBER

CRD42018076076.

How older patients prioritise their multiple health problems: a qualitative study

Background

Patients with multimorbidity often receive diverse treatments; they are subjected to polypharmacy and to a high treatment burden. Hence it is advocated that doctors set individual health and treatment priorities with their patients. In order to apply such a concept, doctors will need a good understanding of what causes patients to prioritise some of their problems over others. This qualitative study explores what underlying reasons patients have when they appraise their health problems as more or less important.

Methods

We undertook semi-structured interviews with a purposive sample of 34 patients (aged 70 years and over) in German general practices. Initially, patients received a comprehensive geriatric assessment, on the basis of which they rated the importance of their uncovered health problems. Subsequently, they were interviewed as to why they considered some of their problems important and others not. Transcripts were analysed using qualitative content analysis.

Results

Patients considered their health problems important, if they were severe, constant, uncontrolled, risky or if they restricted daily activities, autonomy and social inclusion. Important problems often correlated with negative feelings. Patients considered problems unimportant, if they were related to a bearable degree of suffering, less restrictions in activities, or psychological adjustment to diseases. Altogether different reasons occurred on the subject of preventive health issues.

Conclusions

Patients assess health problems as important if they interfere with what they want from life (life values and goals). Psychological adjustment, by contrast, facilitates a downgrading of the importance. Asking patients with multimorbidity, which health problems are important, may guide physicians to treatment priorities and health problems in need of empowerment.

Health-related preferences of older patients with multimorbidity: an evidence map

OBJECTIVES

To systematically identify knowledge clusters and research gaps in the health-related preferences of older patients with multimorbidity by mapping current evidence.

DESIGN

Evidence map (systematic review variant).

DATA SOURCES

MEDLINE, EMBASE, PsycINFO, PSYNDEX, CINAHL and Science Citation Index/Social Science Citation Index/-Expanded from inception to April 2018.

STUDY SELECTION

Studies reporting primary research on health-related preferences of older patients (mean age ≥60 years) with multimorbidity (≥2 chronic/acute conditions).

DATA EXTRACTION

Two independent reviewers assessed studies for eligibility, extracted data and clustered the studies using MAXQDA-18 content analysis software.

RESULTS

The 152 included studies (62% from North America, 28% from Europe) comprised 57 093 patients overall (range 9-9105). All used an observational design except for one interventional study: 63 (41%) were qualitative (59 cross-sectional, 4 longitudinal), 85 (57%) quantitative (63 cross-sectional, 22 longitudinal) and 3 (2%) used mixed methods. The setting was specialised care in 85 (56%) and primary care in 54 (36%) studies. We identified seven clusters of studies on preferences: end-of-life care (n=51, 34%), self-management (n=34, 22%), treatment (n=32, 21%), involvement in shared decision making (n=25, 17%), health outcome prioritisation/goal setting (n=19, 13%), healthcare service (n=12, 8%) and screening/diagnostic testing (n=1, 1%). Terminology (eg, preferences, views and perspectives) and concepts (eg, trade-offs, decision regret, goal setting) used to describe health-related preferences varied substantially between studies.

CONCLUSION

Our study provides the first evidence map on the preferences of older patients with multimorbidity. Included studies were mostly conducted in developed countries and covered a broad range of issues. Evidence on patient preferences concerning decision-making on screening and diagnostic testing was scarce. Differences in employed terminology, decision-making components and concepts, as well as the sparsity of intervention studies, are challenges for future research into evidence-based decision support seeking to elicit the preferences of older patients with multimorbidity and help them construct preferences.

TRIAL REGISTRATION NUMBER

Open Science Framework (OSF): DOI 10.17605/OSF.IO/MCRWQ.

Where Have All the Patients Gone? Profile of US Adults Who Report Doctor-Diagnosed Arthritis But Are Not Being Treated

BACKGROUND

Patients only benefit from clinical management of arthritis if they are under the care of a physician or other health professional.

OBJECTIVES

We profiled adults who reported doctor-diagnosed arthritis who are not currently being treated for it to understand better who they are.

METHODS

Individuals with no current treatment (NCT) were identified by "no" to "Are you currently being treated by a doctor or other health professional for arthritis or joint symptoms?" Demographics, current symptoms, physical functioning, arthritis limitations and interference in life activities, and level of agreement with treatment and attitude statements were assessed in this cross-sectional, descriptive study of noninstitutionalized US adults aged 45 years or older with self-reported, doctor-diagnosed arthritis (n = 1793).

RESULTS

More than half of the study population, 52%, reported NCT (n = 920). Of those with NCT, 27% reported fair/poor health, 40% reported being limited by their arthritis, 51% had daily arthritis pain, 59% reported 2 or more symptomatic joints, and 19% reported the lowest third of physical functioning. Despite NCT, 83% with NCT agreed or strongly agreed with the importance of seeing a doctor for diagnosis and treatment.

CONCLUSIONS

Greater than half of those aged 45 years or older with arthritis were not currently being treated for it, substantial proportions of whom experienced severe symptoms and poor physical function and may benefit from clinical management and guidance, complemented by community-delivered public health interventions (self-management education, physical activity). Further research to understand the reasons for NCT may identify promising intervention points to address missed treatment opportunities and improve quality of life and functioning.

Living with multimorbidity? The lived experience of multiple chronic conditions in later life

Multimorbidity is defined biomedically as the co-existence of two or more long-term conditions in an individual. Globally, the number of people living with multiple conditions is increasing, posing stark challenges both to the clinical management of patients and the organisation of health systems. Qualitative literature has begun to address how concurrency affects the self-management of chronic conditions, and the concept of illness prioritisation predominates. In this article, we adopt a phenomenological lens to show how older people with multiple conditions experience illness. This UK study was qualitative and longitudinal in design. Sampling was purposive and drew upon an existing cohort study. In total, 15 older people living with multiple conditions took part in 27 in-depth interviews. The practical stages of analysis were guided by Constructivist Grounded Theory. We argue that the concept of multimorbidity as biomedically imagined has limited relevance to lived experience, while concurrency may also be erroneous. In response, we outline a lived experience of multiple chronic conditions in later life, which highlights differences between clinical and lay assumptions and makes the latter visible.

Disease and management beliefs of elderly patients with rheumatoid arthritis and comorbidity: a qualitative study

To explore in elderly patients with rheumatoid arthritis (RA) and comorbidity (1) in which order and why patients prioritize their morbidities with regard to functioning and health, (2) their beliefs about common (age-related) musculoskeletal complaints, and (3) experiences about the influence of comorbidity on medication treatment of RA. Patients between 50 and 85 years with RA and ≥ 1 comorbidity or lifestyle risk factor were invited for a semi-structured interview. Two readers coded the transcripts of the interviews, by using NVivo11 software. Fifteen patients (14 women; mean age 67 years (range 51-83 years); mean disease duration 14 years (range 1-39 years)) were interviewed. Only 3 (20%) out of 15 patients prioritized RA over their comorbidity; these patients often experienced severe functional limitations. The level of current or (perceived) future disability, risk of dependency, and the perceived lethality of a condition were considered by participants when prioritizing morbidities. Most participants had misconceptions about common age-related musculoskeletal complaints. Consequently, these participants attributed all joint complaints or even all physical complaints to RA, disregarding degenerative joint disease and physiological aging as alternative diagnoses. Half of the participants ever had to change RA medication because of comorbidity. Most of these patients had prioritized the comorbidity, sometimes even over treatment of RA disease activity. Most elderly RA patients with comorbidity prioritize the importance and treatment of comorbidity over RA. Better understanding of patients' beliefs on RA and comorbidity is essential when managing chronic conditions in elderly patients.

Challenged but not threatened: Managing health in advanced age

In this paper we reflect on discussions with people of advanced age in Āotearoa New Zealand, and draw on theoretical frameworks of resilience and place in old age, to explore insights about the ways older people maintain quality of life and health. Twenty community-dwelling people of advanced age (85+) were recruited in 2015-16 from a large multidisciplinary longitudinal study of advanced age. These twenty participated in interviews about health in advanced age, impact of illnesses, interactions with clinicians, access to information, support for managing health, and perceptions of primary care, medications, and other forms of assistance. We use a positioning theory framework drawing on thematic and narrative analysis to understand the dynamic ways people in advanced age position themselves and the ways they age well through speech acts and storylines. People in advanced age saw themselves as challenged, rather than threatened, by adversities, and positioned themselves as able to draw on a lifetime of experience and resourcefulness and collaborations with supporters to deal with challenges. Key strategies include downplaying illness and resisting biomedical discourses of complexity, positioning embodied selves as having agency, and creative adaptation in the face of loss. People in advanced age exhibit resilience, maintaining wellbeing, autonomy and good physical and mental quality of life even while living with challenges such as functional decline and multi-morbidities. These findings have significance for supporters of older people, emphasising the need to move away from a narrow focus on problems to working together WITH people in advanced age to offer a more holistic approach that encourages and enhances adaptation and flexibility, rather than rigid and counterproductive coping patterns.

"I had to change so much in my life to live with my new limitations": Multimorbid patients' descriptions of their most bothersome chronic conditions

Objective To characterize diseases that are described as most bothersome by individuals with multiple chronic conditions and to identify themes that characterize their experiences with their most bothersome condition. Methods In a survey of patients at an academic center and a Veterans Affairs hospital, we asked individuals with multiple chronic conditions to identify their most bothersome chronic condition and describe why it is challenging. Standard content analysis methods were used to code responses and identify themes reflecting characteristics of most bothersome conditions. Results The most commonly cited bothersome conditions were chronic pain (52%), diabetes (43%), post-traumatic stress disorder (25%), heart failure (24%), and lung problems (20%). Conditions were described as most bothersome due to: (a) impact on function and quality of life (e.g. active symptoms, activity limitations), (b) health consequences or sequelae (e.g. risk of complications), and (c) challenges associated with treatment or self-management. Patterns of theme dominance varied for conditions with different characteristics. Discussion The conditions that patients with multiple chronic conditions identify as most bothersome vary depending on individuals' diseases and their health-related preferences and priorities. Ascertaining patients' most bothersome conditions and associated challenges, stress, and frustrations may help ensure that management decisions are aligned with patient preferences and priorities.

Self-Management of Multiple Chronic Conditions by Community-Dwelling Older Adults: A Concept Analysis

The proportion of the aging population living with multiple chronic conditions (MCC) is increasing. Self-management is valuable in helping individuals manage MCC. The purpose of this study was to conduct a concept analysis of self-management in community-dwelling older adults with MCC using Walker and Avant's method. The review included 30 articles published between 2000 and 2017. The following attributes were identified: (a) using financial resources for chronic disease management, (b) acquiring health- and disease-related education, (c) making use of ongoing social supports, (d) responding positively to health changes, (e) ongoing engagement with the health system, and (f) actively participating in sustained disease management. Self-management is a complex process; the presence of these attributes increases the likelihood that an older adult will be successful in managing the symptoms of MCC.

Validating the Patient Experience with Treatment and Self-Management (PETS), a patient-reported measure of treatment burden, in people with diabetes

Aims

To validate a comprehensive general measure of treatment burden, the Patient Experience with Treatment and Self-Management (PETS), in people with diabetes.

Methods

We conducted a secondary analysis of a cross-sectional survey study with 120 people diagnosed with type 1 or type 2 diabetes and at least one additional chronic illness. Surveys included established patient-reported outcome measures and a 48-item version of the PETS, a new measure comprised of multi-item scales assessing the burden of chronic illness treatment and self-care as it relates to nine domains: medical information, medications, medical appointments, monitoring health, interpersonal challenges, health care expenses, difficulty with health care services, role activity limitations, and physical/mental exhaustion from self-management. Internal reliability of PETS scales was determined using Cronbach’s alpha. Construct validity was determined through correlation of PETS scores with established measures (measures of chronic condition distress, medication satisfaction, self-efficacy, and global well-being), and known-groups validity through comparisons of PETS scores across clinically distinct groups. In an exploratory test of predictive validity, step-wise regressions were used to determine which PETS scales were most associated with outcomes of chronic condition distress, overall physical and mental health, and medication adherence.

Results

Respondents were 37–88 years old, 59% female, 29% non-white, and 67% college-educated. PETS scales showed good reliability (Cronbach’s alphas ≥0.74). Higher PETS scale scores (greater treatment burden) were correlated with more chronic condition distress, less medication convenience, lower self-efficacy, and worse general physical and mental health. Participants less (versus more) adherent to medications and those with more (versus fewer) health care financial difficulties had higher mean PETS scores. Medication burden was the scale that was most consistently associated with well-being and patient-reported adherence.

Conclusion

The PETS is a reliable and valid measure for assessing perceived treatment burden in people coping with diabetes.

CREATE Wellness: A multi-component behavioral intervention for patients not responding to traditional Cardiovascular disease management

Background/Aims

Cardiovascular disease (CVD) is the leading cause of death in the US. Many patients do not benefit from traditional disease management approaches to CVD risk reduction. Here we describe the rationale, development, and implementation of a multi-component behavioral intervention targeting patients who have persistently not met goals of CVD risk factor control.

Methods

Informed by published evidence, relevant theoretical frameworks, stakeholder advice, and patient input, we developed a group-based intervention (Changing Results: Engage and Activate to Enhance Wellness; “CREATE Wellness”) to address the complex needs of patients with elevated or unmeasured CVD-related risk factors. We are testing this intervention in a randomized trial among patients with persistent (i.e > 2 years) sub-optimal risk factor control despite being enrolled in an advanced and highly successful CVD disease management program.

Results

The CREATE Wellness intervention is designed as a 3 session, group-based intervention combining proven elements of patient activation, health system engagement skills training, shared decision making, care planning, and identification of lifestyle change barriers. Our key learnings in designing the intervention included the value of multi-level stakeholder input and the importance of pragmatic skills training to address barriers to care.

Conclusions

The CREATE Wellness intervention represents an evidence-based, patient-centered approach for patients not responding to traditional disease management. The trial is currently underway at three medical facilities within Kaiser Permanente Northern California and next steps include an evaluation of efficacy, adaptation for non-English speaking patient populations, and modification of the curriculum for web- or phone-based versions.

ClinicalTrials.gov Identifier

NCT02302612.

Prevalence and pattern of co morbidity among type2 diabetics attending urban primary healthcare centers at Bhubaneswar (India)

OBJECTIVE

India has the second largest diabetic population in the world. The chronic nature of the disease and high prevalence of co-existing chronic medical conditions or "co morbidities" makes diabetes management complex for the patient and for health care providers. Hence a strong need was felt to explore the problem of co morbidity among diabetics and its dimensions in primary health care practices.

METHOD

This cross sectional survey was carried out on 912 type 2 diabetes patients attending different urban primary health care facilities at Bhubaneswar. Data regarding existence of co morbidity and demographical details were elicited by a predesigned, pretested questionnaire"Diabetes Co morbidity Evaluation Tool in Primary Care (DCET- PC)". Statistical analyses were done using STATA.

RESULTS

Overall 84% had one ormore than one comorbid condition. The most frequent co morbid conditions were hypertension [62%], acid peptic disease [28%], chronic back ache [22%] and osteoarthritis [21%]. The median number of co morbid conditions among both males and females is 2[IQR = 2]. The range of the number of co morbid conditions was wider among males [0-14] than females [0-6]. The number of co morbidities was highest in the age group > = 60 across both sexes. Most of the male patients below 40 years of age had either single [53%] or three co morbidities [11%] whereas among female patients of the same age group single [40%] or two co morbidities [22%] were more predominantly present. Age was found to be a strong independent predictor for diabetes co morbidity. The odds of having co morbidity among people above poverty line and schedule caste were found to be[OR = 3.50; 95%CI 1.85-6.62]and [OR = 2.46; CI 95%1.16-5.25] respectively. Odds were increased for retired status [OR = 1.21; 95% CI 1.01-3.91] and obesity [OR = 3.96; 95%CI 1.01-15.76].

CONCLUSION

The results show a high prevalence of co morbidities in patients with type 2 diabetes attending urban primary health care facilities. Hypertension, acid peptic disease, chronic back ache and arthritis being the most common, strategies need to be designed taking into account the multiple demands of co morbidities.

Identifying High-Cost, High-Risk Patients Using Administrative Databases in Tuscany, Italy

Objective

(1) Assessing the performance of the algorithm in terms of sensitivity and positive predictive value, considering General Practitioners' (GPs) judgement as benchmark, and (2) describing adverse events (hospitalisation, death, and health services' consumption) of complex patients compared to the general population.

Data Sources

(i) Tuscany administrative database containing health data (2013-5); (ii) lists of complex patients indicated by GPs; and (iii) annual health registry of Tuscany.

Study Design

The present study is a validation study. It compares a list of complex patients extracted through an administrative algorithm (criteria of high health consumption) to a gold standard list of patients indicated by GPs. GPs' decision was subjective but fairly well reasoned. The study compares also adverse outcomes (Emergency Room visits, hospitalisation, and death) between identified complex patients and general population.

Principal Findings

Considering GPs' judgement, the algorithm showed a sensitivity of 72.8% and a positive predictive value of 64.4%. The complex cases presented here have higher incidence rates/100,000 (death 46.8; ER visits 223.2, hospitalisations 110.87, laboratory tests 1284.01, and specialist examinations 870.37) compared to the general population.

Conclusions

The final validated algorithm showed acceptable sensitivity and positive predictive value.

Healthcare provider relational quality is associated with better self-management and less treatment burden in people with multiple chronic conditions

PURPOSE

Having multiple chronic conditions (MCCs) can lead to appreciable treatment and self-management burden. Healthcare provider relational quality (HPRQ) - the communicative and interpersonal skill of the provider - may mitigate treatment burden and promote self-management. The objectives of this study were to 1) identify the associations between HPRQ, treatment burden, and psychosocial outcomes in adults with MCCs, and 2) determine if certain indicators of HPRQ are more strongly associated than others with these outcomes.

PATIENTS AND METHODS

This is a cross-sectional survey study of 332 people with MCCs. Patients completed a 7-item measure of HPRQ and measures of treatment and self-management burden, chronic condition distress, self-efficacy, provider satisfaction, medication adherence, and physical and mental health. Associations between HPRQ, treatment burden, and psychosocial outcomes were determined using correlational analyses and independent samples t-tests, which were repeated in item-level analyses to explore which indicators of HPRQ were most strongly associated with the outcomes.

RESULTS

Most respondents (69%) were diagnosed with ≥3 chronic conditions. Better HPRQ was found to be associated with less treatment and self-management burden and better psychosocial outcomes (P<0.001), even after controlling for physical and mental health. Those reporting 100% adherence to prescribed medications had higher HPRQ scores than those reporting less than perfect adherence (P<0.001). HPRQ items showing the strongest associations with outcomes were "my healthcare provider spends enough time with me", "my healthcare provider listens carefully to me", and "I have trust in my healthcare provider".

CONCLUSION

Good communication and interpersonal skills of healthcare providers may lessen feelings of treatment burden and empower patients to feel confident in their self-management. Patient trust in the provider is an important element of HPRQ. Educating healthcare providers about the importance of interpersonal and relational skills could lead to more patient-centered care.

Community to clinic navigation to improve diabetes outcomes

Rural residents experience rates of Type 2 Diabetes Mellitus (T2DM) that are considerably higher than their urban or suburban counterparts. Two primary modifiable factors, self-management and formal clinical management, have potential to greatly improve diabetes outcomes. “Community to Clinic Navigation to Improve Diabetes Outcomes,” is the first known randomized clinical trial pilot study to test a hybrid model of diabetes self-management education plus clinical navigation among rural residents with T2DM. Forty-one adults with T2DM were recruited from two federally qualified health centers in rural Appalachia from November 2014–January 2015. Community health workers provided navigation, including helping participants understand and implement a diabetes self-management program through six group sessions and, if needed, providing assistance in obtaining clinic visits (contacting providers' offices for appointments, making reminder calls, and facilitating transportation and dependent care). Pre and post-test data were collected on T2DM self-management, physical measures, demographics, psychosocial factors, and feasibility (cost, retention, and satisfaction). Although lacking statistical significance, some outcomes indicate trends in positive directions, including diet, foot care, glucose monitoring, and physical health, including decreased HbA1c and triglyceride levels. Process evaluations revealed high levels of satisfaction and feasibility. Due to the limited intervention dose, modest program expenditures (~$29,950), and a severely affected population most of whom had never received diabetes education, outcomes were not as robust as anticipated. Given high rates of satisfaction and retention, this culturally appropriate small group intervention holds promise for hard to reach rural populations. Modifications should include expanded recruitment venues, sample size, intervention dosage and longer term assessment.

•

Community to clinic navigation combined diabetes self-management and navigation.

•

CCN showed some positive trends in diet, triglycerides, self-care, and diabetes.

•

CCN was feasible (low cost and high retention) and satisfactory.

•

Increasing dose, length, and recruitment venues may improve the CCN intervention.

Patient prioritization of comorbid chronic conditions in the Veteran population: Implications for patient-centered care

Objective:

Patients with comorbid chronic conditions may prioritize some conditions over others; however, our understanding of factors influencing those prioritizations is limited. In this study, we sought to identify and elaborate a range of factors that influence how and why patients with comorbid chronic conditions prioritize their conditions.

Methods:

We conducted semi-structured, one-on-one interviews with 33 patients with comorbidities recruited from a single Veterans Health Administration Medical Center.

Findings:

The diverse factors influencing condition prioritization reflected three overarching themes: (1) the perceived role of a condition in the body, (2) self-management tasks, and (3) pain. In addition to these themes, participants described the rankings that they believed their healthcare providers would assign to their conditions as an influencing factor, although few reported having shared their priorities or explicitly talking with providers about the importance of their conditions.

Conclusion:

Studies that advance understanding of how and why patients prioritize their various conditions are essential to providing care that is patient-centered, reflecting what matters most to the individual while improving their health. This analysis informs guideline development efforts for the care of patients with comorbid chronic conditions as well as the creation of tools to promote patient–provider communication regarding the importance placed on different conditions.

Development and validation of the Patient Experience with Treatment and Self-management (PETS): a patient-reported measure of treatment burden

PURPOSE

The purpose of this study was to develop and validate a new comprehensive patient-reported measure of treatment burden-the Patient Experience with Treatment and Self-management (PETS).

METHODS

A conceptual framework was used to derive the PETS with items reviewed and cognitively tested with patients. A survey battery, including a pilot version of the PETS, was mailed to 838 multi-morbid patients from two healthcare institutions for validation.

RESULTS

A total of 332 multi-morbid patients returned completed surveys. Diagnostics supported deletion and consolidation of some items and domains. Confirmatory factor analysis supported a domain model for scaling comprised of 9 factors: medical information, medications, medical appointments, monitoring health, interpersonal challenges, medical/healthcare expenses, difficulty with healthcare services, role/social activity limitations, and physical/mental exhaustion. Scales showed good internal consistency (α range 0.79-0.95). Higher PETS scores, indicative of greater treatment burden, were correlated with more distress, less satisfaction with medications, lower self-efficacy, worse physical and mental health, and lower convenience of healthcare (Ps < 0.001). Patients with lower health literacy, less adherence to medications, and more financial difficulties reported higher PETS scores (Ps < 0.01).

CONCLUSION

A comprehensive patient-reported measure of treatment burden can help to better characterize the impact of treatment and self-management burden on patient well-being and guide care toward minimally disruptive medicine.

Comorbidity: Reconsidering the Unit of Analysis

In this short essay, I wish to briefly discuss smoking, polypharmacy, the human biome and multispecies relations, and biomedicalization as a means of stretching the common ways we think about comorbidity. My intent is to expand our thinking about comorbidity and multimorbidity beyond the individual as a unit of analysis, to reframe comorbidity in relation to trajectories of risk, and to address comorbid states of our own making when the treatment of one health problem results in the experience of additional health problems. I do so as a corrective to what I see as an overly narrow focus on comorbidity as co-occurring illnesses within a single individual, and as a complement to critical medical anthropological assessments of synergistic comorbid conditions (syndemics) occurring in structurally vulnerable populations living in environments of risk exposed to macro and micro pathogenic agents.

Rhinitis in the Elderly

By 2050, the US aging population will nearly double. It will be increasingly important for health care providers to diagnose and manage rhinitis. Nasal symptoms of rhinorrhea, congestion, sneezing, nasal/ocular pruritus, and postnasal drainage affect up to 32% of older adults, and can impact quality of life. Several underlying factors associated with aging may contribute to the pathogenesis of rhinitis in older adults. Although treatment options for rhinitis exist, special considerations need to be made because comorbidities, limited income, memory loss, and side effects of medications are common in older adults and may impact outcomes.

Context and complexity: the meaning of self-management for older adults with heart disease

Self-management policies have presented opportunities for patients with long-term conditions to take control and actively improve their health. However, the work of self-management appears to be packaged in the form of essential and desirable skills and attributes required for success. This article presents the findings of a qualitative study, employing longitudinal diary interviews with 21 patients aged between 60 and 85 years diagnosed with coronary heart disease from three contrasting general practice areas. Drawing on concepts of the care of the self and the reflexive self, this article presents the diversity of self-management practices by older patients in the context of their lifeworld. Illustrated through individual case studies, it clearly identifies where patients are engaged self-managers with the agency, knowledge and self-discipline to modify their behaviour for an improved health outcome. This study highlights their life and illness perspectives as well as those of patients who are burdened with emotional insecurity, comorbidities and caring responsibilities. It shows the spectrum of relationships with health professionals that influence engaged self-management. We suggest that policy initiatives that favour behavioural change neglect social context and the individualised practices that are a necessary response to structural and psychosocial constraints.

How Can eHealth Technology Address Challenges Related to Multimorbidity? Perspectives from Patients with Multiple Chronic Conditions

BACKGROUND

Patient eHealth technology offers potential support for disease self-management, but the value of existing applications for patients with multiple chronic conditions (MCCs) is unclear.

OBJECTIVES

To understand self-management and health care navigation challenges that patients face due to MCCs and to identify opportunities to support these patients through new and enhanced eHealth technology.

DESIGN

After administering a screening survey, we conducted 10 focus groups of 3-8 patients grouped by age, sex, and common chronic conditions. Patients discussed challenges associated with having MCCs and their use of (and desires from) technology to support self-management. Three investigators used standard content analysis methods to code the focus group transcripts. Emergent themes were reviewed with all collaborators, and final themes and representative quotes were validated with a sample of participants.

PARTICIPANTS

Fifty-three individuals with ≥3 chronic conditions and experience using technology for health-related purposes.

KEY RESULTS

Focus group participants had an average of five chronic conditions. Participants reported using technology most frequently to search for health information (96%), communicate with health care providers (92%), track medical information (83%), track medications (77%), and support decision-making about treatment (55%). Three themes emerged to guide eHealth technology development: (1) Patients with MCCs manage a high volume of information, visits, and self-care tasks; (2) they need to coordinate, synthesize, and reconcile health information from multiple providers and about different conditions; (3) their unique position at the hub of multiple health issues requires self-advocacy and expertise. Focus groups identified desirable eHealth resources and tools that reflect these themes.

CONCLUSIONS

Although patients with multiple health issues use eHealth technology to support self-care for specific conditions, they also desire tools that transcend disease boundaries. By addressing the holistic needs of patients with MCCs, eHealth technology can advance health care from a disease-centered to a patient-centered model.

Challenges of self-management when living with multiple chronic conditions: systematic review of the qualitative literature

OBJECTIVE

To explore the perspectives of patients who live with multiple chronic conditions as they relate to the challenges of self-management.

DATA SOURCES

On September 30, 2013, we searched MEDLINE, EMBASE, and CINAHL using relevant key words including chronic disease, comorbidity, multimorbidity, multiple chronic conditions, self-care, self-management, perspective, and perception.

STUDY SELECTION

Three reviewers assessed and extracted the data from the included studies after study quality was rated. Qualitative thematic synthesis method was then used to identify common themes. Twenty-three articles met the inclusion criteria, with most coming from the United States.

SYNTHESIS

Important themes raised by people living with multiple chronic conditions related to their ability to self-manage included living with undesirable physical and emotional symptoms, with pain and depression highlighted. Issues with conflicting knowledge, access to care, and communication with health care providers were raised. The use of cognitive strategies, including reframing, prioritizing, and changing beliefs, was reported to improve people's ability to self-manage their multiple chronic conditions.

CONCLUSION

This study provides a unique view into patients' perspectives of living with multiple chronic conditions, which are clearly linked to common functional challenges as opposed to specific diseases. Future policy and programming in self-management support should be better aligned with patients' perspectives on living with multiple chronic conditions. This might be achieved by ensuring a more patient-centred approach is adopted by providers and health service organizations.

Self-management priority setting and decision-making in adults with multimorbidity: a narrative review of literature

OBJECTIVES

The purpose of this narrative review was to synthesize current research findings related to self-management, in order to better understand the processes of priority setting and decision-making among adults with multimorbidity.

DESIGN

A narrative literature review was undertaken, synthesizing findings from published, peer-reviewed empirical studies that addressed priority setting and/or decision-making in self-management of multimorbidity.

DATA SOURCES

A search of PubMed, PsychINFO, CINAHL and SocIndex databases was conducted from database inception through December 2013. References lists from selected empirical studies and systematic reviews were evaluated to identify any additional relevant articles.

REVIEW METHODS

Full text of potentially eligible articles were reviewed and selected for inclusion if they described empirical studies that addressed priority setting or decision-making in self-management of multimorbidity among adults. Two independent reviewers read each selected article and extracted relevant data to an evidence table. Processes and factors of multimorbidity self-management were identified and sorted into categories of priority setting, decision-making, and facilitators/barriers.

RESULTS

Thirteen articles were selected for inclusion; most were qualitative studies describing processes, facilitators, and barriers of multimorbidity self-management. The findings revealed that patients prioritize a dominant chronic illness and re-prioritize over time as conditions and treatments change; that multiple facilitators (e.g. support programs) and barriers (e.g. lack of financial resources) impact individuals' self-management priority setting and decision-making ability; as do individual beliefs, preferences, and attitudes (e.g., perceived personal control, preferences regarding treatment).

CONCLUSIONS

Health care providers need to be cognizant that individuals with multimorbidity engage in day-to-day priority setting and decision-making among their multiple chronic illnesses and respective treatments. Researchers need to develop and test interventions that support day-to-day priority setting and decision-making and improve health outcomes for individuals with multimorbidity.

The experience of adults with multimorbidity: a qualitative study

Background

Findings from several countries indicate that the prevalence of multimorbidity is very high among clients of primary healthcare. A deeper understanding of patients’ experiences from their own perspective can greatly enrich any intervention to help them live as well as possible with multimorbidity.

Objective

To describe the fundamental structure of adults’ experience with multimorbidity.

Design

A phenomenological study was undertaken to describe the experiences of 11 adults with multimorbidity. These adults participated in two semi-structured interviews, the content of which was rigorously analyzed.

Results

At the core of the study participants’ multimorbidity experience are the impression of aging prematurely, difficulties with self-care management, and issues with access to the healthcare system, which contribute to the problem’s complexity. Despite these issues, participants with multimorbidity report attempting to take control of their situation and adjusting to daily living.

Conclusions

The description of this experience, through the systemic vision of participants, provides a better understanding of the realities experienced by people with multimorbidity.

Journal of Comorbidity 2014;4:11–21

Costs associated with multimorbidity among VA patients

BACKGROUND

Multimorbidity (the presence of multiple chronic conditions) is associated with high levels of healthcare utilization and associated costs. We investigated the association between number of chronic conditions and costs of care for nonelderly and elderly Veterans Affairs (VA) patients, and estimated mean VA healthcare costs for the most prevalent and most costly combinations of 3 conditions (triads).

METHODS

We identified a cohort of 5,233,994 patients who received care within the VA system in fiscal year 2010. We estimated the costs of VA care for each patient using established methods and aggregated costs for inpatient care, outpatient care, prescription drugs, and contract care. Using ICD-9 diagnosis fields from all inpatient and outpatient records, we determined the prevalence of 28 chronic conditions and all condition triads. We then compared the condition-cost gradient, most prevalent triads, and most costly triads among nonelderly (below 65 y) and elderly (65 y and above) patients.

RESULTS

Almost one third of nonelderly and slightly more than a third of elderly VA patients had ≥3 conditions, but these patients accounted for 65% and 67% of total VA healthcare costs, respectively. The most common triad of chronic conditions for both nonelderly and elderly patients was diabetes, hyperlipidemia, and hypertension (24% and 29%, respectively). Conditions that were present in the most costly triads included spinal cord injury, heart failure, renal failure, ischemic heart disease, peripheral vascular disease, stroke, and depression. Although patients with the most costly triads had average costs that were 3 times higher than average costs among patients with ≥3 conditions, the prevalence of these costly triads was extremely low (0.1%-0.4%).

CONCLUSIONS

Patients with multiple chronic conditions account for a disproportionate share of VA healthcare expenditures. Interventions that aim to optimize care and contain costs for multimorbid patients need to incorporate strategies specific to the most prevalent and the most costly combinations of conditions.

Self-management of multiple chronic conditions among African American women with asthma: a qualitative study

OBJECTIVE

African American women are disproportionately burdened by asthma morbidity and mortality and may be more likely than asthma patients in general to have comorbid health conditions. This study sought to identify the self-management challenges faced by African American women with asthma and comorbidities, how they prioritize their conditions and behaviors perceived as beneficial across conditions.

METHODS

In-depth interviews were conducted with 25 African-American women (mean age 52 years) with persistent asthma and at least one of the following: diabetes, heart disease or arthritis. Information was elicited on women's experiences managing asthma and concurrent health conditions. The constant-comparison analytic method was used to develop and apply a coding scheme to interview transcripts. Key themes and subthemes were identified.

RESULTS

Participants reported an average of 5.7 comorbidities. Fewer than half of the sample considered asthma their main health problem; these perceptions were influenced by beliefs about the relative controllability, predictability and severity of their health conditions. Participants reported ways in which comorbidities affected asthma management, including that asthma sometimes took a "backseat" to conditions considered more troublesome or worrisome. Mood problems, sometimes attributed to pain or functional limitations resulting from comorbidities, reduced motivation for self-management. Women described how asthma affected comorbidity management; e.g. by impeding recommended exercise. Some self-management recommendations, such as physical activity and weight control, were seen as beneficial across conditions.

CONCLUSIONS

Multiple chronic conditions that include asthma may interact to complicate self-management of each condition. Additional clinical attention and self-management support may help to reduce multimorbidity-related challenges.