Measures of multimorbidity and morbidity burden for use in primary care and community settings: a systematic review and guide

GrimAge is elevated in older adults with mild COVID-19 an exploratory analysis

COVID-19 has been contained; however, the side effects associated with its infection continue to be a challenge for public health, particularly for older adults. On the other hand, epigenetic status contributes to the inter-individual health status and is associated with COVID-19 severity. Nevertheless, current studies focus only on severe COVID-19. Considering that most of the worldwide population developed mild COVID-19 infection. In the present exploratory study, we aim to analyze the association of mild COVID-19 with epigenetic ages (HorvathAge, HannumAge, GrimAge, PhenoAge, SkinAge, and DNAmTL) and clinical variables obtained from a Mexican cohort of older adults. We found that all epigenetic ages significantly differ from the chronological age, but only GrimAge is elevated. Additionally, both the intrinsic epigenetic age acceleration (IEAA) and the extrinsic epigenetic age acceleration (EEAA) are accelerated in all patients. Moreover, we found that immunological estimators and DNA damage were associated with PhenoAge, SkinBloodHorvathAge, and HorvathAge, suggesting that the effects of mild COVID-19 on the epigenetic clocks are mainly associated with inflammation and immunology changes. In conclusion, our results show that the effects of mild COVID-19 on the epigenetic clock are mainly associated with the immune system and an increase in GrimAge, IEAA, and EEAA.

Comorbidities and use of health services in people with diabetes mellitus according to risk levels by adjusted morbidity groups

BACKGROUND

People with diabetes mellitus frequently have other comorbidities and involve greater use of primary and hospital care services. The aim of this study was to describe the comorbidities and use of primary and hospital care services of people with diabetes according to their risk level by adjusted morbidity groups (AMG) and to analyse the factors associated with the utilisation of these services.

METHODS

Cross-sectional study. People with diabetes were identified within the population of patients with chronic conditions of an urban health care centre by the AMG stratification tool integrated into the primary health care electronic clinical record of the Community of Madrid. Sociodemographic, functional, clinical characteristics and annual health care services utilisation variables were collected. Univariate, bivariate and Poisson regression analyses were performed.

RESULTS

A total of 1,063 people with diabetes were identified, representing 10.8% of patients with chronic conditions within the health centre. A total of 51.4% were female, the mean age was 70 years, 94.4% had multimorbidity. According to their risk level, 17.8% were high-risk, 40.6% were medium-risk and 41.6% were low-risk. The most prevalent comorbidities were hypertension (70%), dyslipidaemia (67%) and obesity (32.4%). Almost 50% were polymedicated. Regarding health services utilisation, 94% were users of primary care, and 59.3% were users of hospital care. Among the main factors associated with the utilisation of both primary and hospital care services were AMG risk level and complexity index. In primary care, utilisation was also associated with the need for primary caregivers, palliative care and comorbidities such as chronic heart failure and polymedication, while in hospital care, utilisation was also associated with comorbidities such as cancer, chronic obstructive pulmonary disease or depression.

CONCLUSIONS

People with diabetes were older, with important needs for care, many associated comorbidities and polypharmacy that increased in parallel with the patient's risk level and complexity. The utilisation of primary and hospital care services was very high, being more frequent in primary care. Health services utilization were principally associated with functional factors related to the need of care and with clinical factors such as AMG medium and high-risk level, more complexity index, some serious comorbidities and polymedication.

Identifying individuals with complex and long-term health-care needs using the Johns Hopkins Adjusted Clinical Groups System: A comparison of data from primary and specialist health care

AIMS

This study aimed to present the Johns Hopkins Adjusted Clinical Groups (ACG) System risk stratification profile of a total adult population of somatic health-care users when using data from either general practitioners (GPs) or hospital services and to compare the number and characteristics of individuals identified as having complex and long-term health-care needs in each data source.

METHODS

This was a registry-based study that included all adult residents (N=168,285) in four municipalities in Central Norway who received somatic health care during 2013. Risk profiles were generated using the ACG System based on age, sex and diagnoses registered by GPs or the local hospital. ACG output variables on number of chronic conditions, frailty and concurrent resource utilisation were chosen as indicators of complexity.

RESULTS

Nearly nine out of 10 (83.9%) of the population had been in contact with a GP, and 35.4% with the hospital. The mean number of diagnoses (3.0) was equal in both sources. A larger proportion of the population had higher risk scores in all variables except frailty when comparing hospital data to GP data. This was also found when comparing individuals identified as having complex and long-term health-care needs. A similar proportion of the population was found to have complex and long-term health-care needs (hospital 6.7%, GP 6.3%), but only one in five (21.5%) were identified in both data sets.

CONCLUSIONS

As data from GPs and hospitals identified mostly different individuals with complex and long-term health-care needs, combining data sources is likely to be the best option for identifying those most in need of special attention.

Care dependency in older stroke patients with comorbidities: a latent profile analysis

Objectives

To explore latent profiles of care dependency in older stroke patients with comorbidities and to analyze the factors influencing different latent profiles.

Methods

A total of 312 older ischemic stroke patients with comorbidities were included in the analysis. Latent Profile Analysis (LPA) was used to classify the participants into potential subgroups with different types of care dependency. The influencing factors of the classification of care dependency subgroups were determined using multivariate Logistic regression analysis.

Results

The care dependency score of older ischemic stroke patients with comorbidities was (51.35 ± 13.19), and the patients could be classified into 3 profiles, namely Universal dependency (24.0%), Moderate activity-social-learning dependency (28.0%), and Mild activity-social-learning dependency (48.0%); caregiver, BI at admission, and functional impairments were independent factors influencing care dependency (P < 0.05).

Conclusion

There are three latent profiles of care dependency in older ischemic stroke patients with comorbidities. According to the characteristics of various populations, medical staff are able to implement specific interventions to lower the level of dependency and further improve the quality of life of patients.

The economic burden of multimorbidity: Protocol for a systematic review

Multimorbidity, also known as multiple long-term conditions, leads to higher healthcare utilisation, including hospitalisation, readmission, and polypharmacy, as well as a financial burden to families, society, and nations. Despite some progress, the economic burden of multimorbidity remains poorly understood. This paper outlines a protocol for a systematic review that aims to identify and synthesise comprehensive evidence on the economic burden of multimorbidity, considering various definitions and measurements of multimorbidity, including their implications for future cost-of-illness analyses. The review will include studies involving people of all ages with multimorbidity without any restriction on location and setting. Cost-of-illness studies or studies that examined economic burden including model-based studies will be included, and economic evaluation studies will be excluded. Databases including Scopus (that includes PubMed/MEDLINE), Web of Science, CINAHL Plus, PsycINFO, NHS EED (including the HTA database), and the Cost-Effectiveness Analysis Registry, will be searched until March 2024. The risk of bias within included studies will be independently assessed by two authors using appropriate checklists. A narrative synthesis of the main characteristics and results, by definitions and measurements of multimorbidity, will be conducted. The total economic burden of multimorbidity will be reported as mean annual costs per patient and disaggregated based on counts of diseases, disease clusters, and weighted indices. The results of this review will provide valuable insights for researchers into the key cost components and areas that require further investigation in order to improve the rigour of future studies on the economic burden of multimorbidity. Additionally, these findings will broaden our understanding of the economic impact of multimorbidity, inform us about the costs of inaction, and guide decision-making regarding resource allocation and cost-effective interventions. The systematic review's results will be submitted to a peer-reviewed journal, presented at conferences, and shared via an online webinar for discussion.

Chronic Disease Patterns and Their Relationship With Health-Related Quality of Life in South Korean Older Adults With the 2021 Korean National Health and Nutrition Examination Survey: Latent Class Analysis

BACKGROUND

Improved life expectancy has increased the prevalence of older adults living with multimorbidities, which likely deteriorates their health-related quality of life (HRQoL). Understanding which chronic conditions frequently co-occur can facilitate person-centered care tailored to the needs of individuals with specific multimorbidity profiles.

OBJECTIVE

The study objectives were to (1) examine the prevalence of multimorbidity among Korean older adults (ie, those aged 65 years and older), (2) investigate chronic disease patterns using latent class analysis, and (3) assess which chronic disease patterns are more strongly associated with HRQoL.

METHODS

A sample of 1806 individuals aged 65 years and older from the 2021 Korean National Health and Nutrition Examination Survey was analyzed. Latent class analysis was conducted to identify the clustering pattern of chronic diseases. HRQoL was assessed by an 8-item health-related quality of life scale (HINT-8). Multiple linear regression was used to analyze the association with the total score of the HINT-8. Logistic regression analysis was performed to evaluate the odds ratio of having problems according to the HINT-8 items.

RESULTS

The prevalence of multimorbidity in the sample was 54.8%. Three chronic disease patterns were identified: relatively healthy, cardiometabolic condition, arthritis, allergy, or asthma. The total scores of the HINT-8 were the highest in participants characterized as arthritis, allergy, or asthma group, indicating the lowest quality of life.

CONCLUSIONS

Current health care models are disease-oriented, meaning that the management of chronic conditions applies to a single condition and may not be relevant to those with multimorbidities. Identifying chronic disease patterns and their impact on overall health and well-being is critical for guiding integrated care.

Patterns and Predictors of HIV Comorbidity among Adolescents and Young Adults in South Africa

Adolescents and young adults (AYA) are identified as a high-risk group for HIV acquisition. However, health services are generally not sensitive to the needs of this priority population. In addition, multimorbidity (having more than one disease in an individual) is not well studied among AYA, as it is typically associated with older individuals. This paper reports on commonly co-occurring disease conditions and disease patterns in AYA, aged 15-24 years, who took part in the 2016 South African Demographic and Health Survey. Chi-squared tests and logistic regression were used to examine the weighted prevalence of disease among those with/without HIV, and the risk factors associated with HIV. Latent class analysis (LCA) was conducted to identify common co-occurring diseases. Of the 1787 individuals included in our analysis, the weighted prevalence of HIV was 8.7%. Hypertension (30.5%), anaemia (35.8%) and diabetes (2.0%) were more prevalent among those with HIV. HIV and anaemia, hypertension and anaemia, and HIV and hypertension comprise the largest disease burden of co-occurring diseases. Co-morbidity was high among those with HIV, emphasizing the need for integrated care of HIV and non-communicable diseases.

Socioeconomic, Health Services, and Multimorbidity Disparities in Chinese Older Adults

INTRODUCTION

As one of the world's most populous countries, China persistently confronts a significant multimorbidity burden. This study aimed to elucidate the multimorbidity burden experienced by Chinese older adults, explore its interplay with socioeconomic disparity, and investigate potential correlations between these provincial disparities and health services availability.

METHODS

The fourth wave of China's national Urban and Rural Elderly Population study, conducted in 2015, was used to construct a multimorbidity index and elucidate the geographic differences in the multimorbidity burden. Incorporating macrolevel indicators about socioeconomic and health services availability, quantile regression and Spearman correlation analyses were employed to investigate the relationship between multimorbidity and socioeconomic disparities and examine the potential linkages between these provincial disparities and health services availability. Analyses were performed in 2023.

RESULTS

The final analysis included a total of 213,857 older adults. At the provincial level, significant geographic disparities in multimorbidity burden were identified. After adjusting for individual social determinants of health, an independent association was found between the human development index and a higher multimorbidity index (coefficient= -0.22; 95% CI= -0.24, -0.19). Furthermore, a significant positive correlation emerged between human development index and both population and geographic densities of health services availability. Notably, geographic density displayed greater inequality (Gini coefficients=0.45-0.48) than population density (Gini coefficients=0.03-0.10).

CONCLUSIONS

This study demonstrates that multimorbidity burden in China is linked to provincial socioeconomic disparities and that inequality in health services availability may account for this, which would advocate for a need to reduce disparities in health services availability.

Prevalence of multimorbidity and polypharmacy among adults and older adults: a systematic review

Multimorbidity (multiple conditions) and polypharmacy (multiple medications) are increasingly common, yet there is a need to better understand the prevalence of co-occurrence. In this systematic review, we examined the prevalence of multimorbidity and polypharmacy among adults (≥18 years) and older adults (≥65 years) in clinical and community settings. Six electronic databases were searched, and 87 studies were retained after two levels of screening. Most studies focused on adults 65 years and older and were done in population-based community settings. Although the operational definitions of multimorbidity and polypharmacy varied across studies, consistent cut-points (two or more conditions and five or more medications) were used across most studies. In older adult samples, the prevalence of multimorbidity ranged from 4·8% to 93·1%, while the prevalence of polypharmacy ranged from 2·6% to 86·6%. High heterogeneity between studies indicates the need for more consistent reporting of specific lists of conditions and medications used in operational definitions.

ESPEN practical guideline: Nutritional support for polymorbid medical inpatients

BACKGROUND

Disease-related malnutrition in polymorbid medical inpatients is a highly prevalent syndrome associated with significantly increased morbidity, disability, short- and long-term mortality, impaired recovery from illness, and healthcare costs.

AIM

As there are uncertainties in applying disease-specific guidelines to patients with multiple conditions, our aim was to provide evidence-based recommendations on nutritional support for the polymorbid patient population hospitalized in medical wards.

METHODS

The 2023 update adheres to the standard operating procedures for ESPEN guidelines. We undertook a systematic literature search for 15 clinical questions in three different databases (Medline, Embase and the Cochrane Library), as well as in secondary sources (e.g., published guidelines), until July 12th, 2022. Retrieved abstracts were screened to identify relevant studies that were used to develop recommendations (including SIGN grading), which was followed by submission to Delphi voting. Here, the practical version of the guideline is presented which has been shortened and equipped with flow charts for patients care.

RESULTS

32 recommendations (7× A, 11× B, 10× O and 4× GPP), which encompass different aspects of nutritional support were included from the scientific guideline including indication, route of feeding, energy and protein requirements, micronutrient requirements, disease-specific nutrients, timing, monitoring and procedure of intervention. Here, the practical version of the guideline is presented which has been shortened and equipped with flow charts for patients care.

CONCLUSIONS

Recent high-quality trials have provided increasing evidence that nutritional support can reduce morbidity and other complications associated with malnutrition in polymorbid patients. The timely screening of patients for risk of malnutrition at hospital admission followed by individualized nutritional support interventions for at-risk patients should be part of routine clinical care and multimodal treatment in hospitals worldwide. Use of this updated practical guideline offers an evidence-based nutritional approach to polymorbid medical inpatients and may improve their outcomes.

Impact of age, comorbidity, and polypharmacy on receipt of systemic therapy in advanced cancers: A retrospective population-based study

INTRODUCTION

Cancer incidence, comorbidity, and polypharmacy increase with age, but the interplay between these factors on receipt of systemic therapy (ST) in advanced cancer has rarely been studied.

MATERIALS AND METHODS

A retrospective cohort study was conducted including patients aged ≥18 years diagnosed from 2004 to 2015 with multiple myeloma (MM) (all stages), lung cancer (stage IV), and stage III-IV non-Hodgkin's lymphoma (NHL), breast, colorectal (CRC), prostate, or ovarian cancer in Manitoba, Canada. Clinical and administrative health data were used to determine demographic and cancer characteristics, treatment history, comorbidity (Charlson Comorbidity Index [CCI] and Resource Utilization Band [RUB]), and polypharmacy (≥6 medications). Multivariable logistic regression was used to evaluate variable associations with receipt of ST and interaction with age.

RESULTS

In total, 17,228 patients were diagnosed with advanced cancer. Ages were distributed as follows: 7% <50 years, 16% 50-59 years, 26% 60-69, 26% 70-79, 24% ≥80 years. ST was administered to 50% of patients. Increased age, polypharmacy, and comorbidity each independently decreased the likelihood of receiving ST. Significant interaction effects were found between age at diagnosis with stage of cancer and cancer type. Differences in probability of ST by cancer stage converged as age increased. In multivariable analysis, adjusting for covariates, patients with MM had the highest odds and lung cancer the lowest odds to receive ST. The impact of comorbidity and polypharmacy did not differ meaningfully with increasing age.

DISCUSSION

Increased age, polypharmacy, and comorbidity were each independently associated with decreased receipt of ST in people with advanced cancers. The impact of comorbidity and polypharmacy did not differ meaningfully with increasing age, while age meaningfully interacted with stage and cancer type.

Comparing a new multimorbidity index with other multimorbidity measures for predicting disability trajectories

BACKGROUND

The optimal multimorbidity measures for predicting disability trajectories are not universally agreed upon. We developed a multimorbidity index among middle-aged and older community-dwelling Chinese adults and compare its predictive ability of disability trajectories with other multimorbidity measures.

METHODS

This study included 17,649 participants aged ≥50 years from the China Health and Retirement Longitudinal Survey 2011-2018. Two disability trajectory groups were estimated using the total disability score differences calculated between each follow-up visit and baseline. A weighted index was constructed using logistic regression models for disability trajectories based on the training set (70 %). The index and the condition count were used, along with the pattern identified by the latent class analysis to measure multimorbidity at baseline. Logistic regression models were used in the training set to examine associations between each multimorbidity measure and disability trajectories. C-statistics, integrated discrimination improvements, and net reclassification indices were applied to compare the performance of different multimorbidity measures in predicting disability trajectories in the testing set (30 %).

RESULTS

In the newly developed multimorbidity index, the weights of the chronic conditions varied from 1.04 to 2.55. The multimorbidity index had a higher predictive performance than the condition count. The condition count performed better than the multimorbidity pattern in predicting disability trajectories.

LIMITATION

Self-reported chronic conditions.

CONCLUSIONS

The multimorbidity index may be considered an ideal measurement in predicting disability trajectories among middle-aged and older community-dwelling Chinese adults. The condition count is also suggested due to its simplicity and superior predictive performance.

Risk factors for osteoporotic hip fracture among community-dwelling older adults: a real-world evidence study

BACKGROUND

Hip fractures in the older adults lead to increased morbidity and mortality. Although a low bone mineral density is considered the leading risk factor, it is essential to recognize other factors that could affect the risk of hip fractures. This study aims to evaluate the contribution of clinical characteristics, patient-reported outcomes, and muscle and aerobic capacity for hip fractures in community-dwelling older adults.

METHODS

This is a retrospective cohort study with real world-data from subjects ≥ 60 years old attending an outpatient clinic in Minas Gerais, Brazil, from May 1, 2019, to August 22, 2022. Data about clinical characteristics (multimorbidity, medications of long-term use, sedative and or tricyclic medications, number of falls), patient-reported outcomes (self-perception of health, self-report of difficulty walking, self-report of vision problems, and self-report of falls) and muscle and aerobic capacity (calf circumference, body mass index, and gait speed) were retrieved from an electronic health record. The association of each potential risk factor and hip fracture was investigated by a multivariable logistic regression analysis adjusted for age and sex.

RESULTS

A total of 7,836 older adults were included with a median age of 80 years (IQR 72-86) and 5,702 (72.7%) were female. Hip fractures occurred in 121 (1.54%) patients. Multimorbidity was associated with an increased risk of hip fracture (OR = 1.12, 95%CI 1.06-1.18) and each episode of fall increased the chance of hip fracture by 1.7-fold (OR = 1.69, 95%CI 1.52-1.80). Patient-reported outcomes associated with increased fracture risk were regular or poor self-perception of health (OR = 1.59, 95%CI 1.06-2.37), self-report of walking difficulty (OR = 3.06, 95%CI 1.93-4.84), and self-report of falls (OR = 2.23, 95%CI 1.47-3.40). Body mass index and calf circumference were inversely associated with hip fractures (OR = 0.91, 95%CI 0.87-0.96 and OR = 0.93, 95%CI 0.88-0.97, respectively), while slow gait speed increased the chance of hip fractures by almost two-fold (OR = 1.80, 95%CI 1.22-2.66).

CONCLUSION

Our study reinforces the importance of identified risk factors for hip fracture in community-dwelling older adults beyond bone mineral density and available fracture risk assessment tools. Data obtained in primary care can help physicians, other health professionals, and public health policies to identify patients at increased risk of hip fractures.

Multimorbidity clusters in adults 50 years or older with and without a history of cancer: National Health Interview Survey, 2018

BACKGROUND

Multimorbidity is increasing among adults in the United States. Yet limited research has examined multimorbidity clusters in persons aged 50 years and older with and without a history of cancer. An increased understanding of multimorbidity clusters may improve the cancer survivorship experience for survivors with multimorbidity.

METHODS

We identified 7580 adults aged 50 years and older with 2 or more diseases-including 811 adults with a history of primary breast, colorectal, cervical, prostate, or lung cancer-from the 2018 National Health Interview Survey. Exploratory factor analysis identified clusters of multimorbidity among cancer survivors and individuals without a history of cancer (controls). Frequency tables and chi-square tests were performed to determine overall differences in sociodemographic characteristics, health-related characteristics, and multimorbidity between groups.

RESULTS

Cancer survivors reported a higher prevalence of having 4 or more diseases compared to controls (57% and 38%, respectively). Our analysis identified 6 clusters for cancer survivors and 4 clusters for controls. Three clusters (pulmonary, cardiac, and liver) included the same diseases for cancer survivors and controls.

CONCLUSIONS

Diseases clustered differently across adults ≥ 50 years of age with and without a history of cancer. Findings from this study may be used to inform clinical care, increase the development and dissemination of multilevel public health interventions, escalate system improvements, and initiate innovative policy reform.

Impact of multimorbidity and complex multimorbidity on healthcare utilisation in older Australian adults aged 45 years or more: a large population-based cross-sectional data linkage study

OBJECTIVES

As life expectancy increases, older people are living longer with multimorbidity (MM, co-occurrence of ≥2 chronic health conditions) and complex multimorbidity (CMM, ≥3 chronic conditions affecting ≥3 different body systems). We assessed the impacts of MM and CMM on healthcare service use in Australia, as little was known about this.

DESIGN

Population-based cross-sectional data linkage study.

SETTING

New South Wales, Australia.

PARTICIPANTS

248 496 people aged ≥45 years who completed the Sax Institute's 45 and Up Study baseline questionnaire.

PRIMARY OUTCOME

High average annual healthcare service use (≥2 hospital admissions, ≥11 general practice visits and ≥2 emergency department (ED) visits) during the 3-year baseline period (year before, year of and year after recruitment).

METHODS

Baseline questionnaire data were linked with hospital, Medicare claims and ED datasets. Poisson regression models were used to estimate adjusted and unadjusted prevalence ratios for high service use with 95% CIs. Using a count of chronic conditions (disease count) as an alternative morbidity metric was requested during peer review.

RESULTS

Prevalence of MM and CMM was 43.8% and 15.5%, respectively, and prevalence increased with age. Across three healthcare settings, MM was associated with a 2.02-fold to 2.26-fold, and CMM was associated with a 1.83-fold to 2.08-fold, increased risk of high service use. The association was higher in the youngest group (45-59 years) versus the oldest group (≥75 years), which was confirmed when disease count was used as the morbidity metric in sensitivity analysis.When comparing impact using three categories with no overlap (no MM/CMM, MM with no CMM, and CMM), CMM had greater impact than MM across all settings.

CONCLUSION

Increased healthcare service use among older adults with MM and CMM impacts on the demand for primary care and hospital services. Which of MM or CMM has greater impact on risk of high healthcare service use depends on the analytic method used. Ageing populations living longer with increasing burdens of MM and CMM will require increased Medicare funding and provision of integrated care across the healthcare system to meet their complex needs.

Scoping Review of Measures of Comorbidities in Heart Failure

BACKGROUND

Comorbidities are risk factors for poor clinical outcomes in patients with heart failure. However, no consensus has been reached on how to assess comorbidities related to clinical outcomes in patients with heart failure.

OBJECTIVE

The aims of this study were to review (1) how comorbidities have been assessed, (2) what chronic conditions have been identified as comorbidities and (3) the rationale for choosing the comorbidity instruments and/or specific comorbidities when exploring clinical outcomes in patients with heart failure.

METHODS

The clinical outcomes of interest were mortality, hospitalization, quality of life, and self-care. Three electronic databases and reference list searches were used in the search.

RESULTS

In this review, we included 39 articles using 3 different ways to assess comorbidities in the relationship with clinical outcomes: using an instrument (ie, Charlson Comorbidity Index), disease count, and including individual comorbidities. A total of 90 comorbidities were investigated in the 39 articles; however, definitions and labels for the diseases were inconsistent across the studies. More than half of the studies (n = 22) did not provide a rationale for selecting the comorbidity instruments and/or all of the specific comorbidities. Some of the rationale for choosing the instruments and/or specific comorbidities was inappropriate.

CONCLUSIONS

We found several issues related to measuring comorbidities when examining clinical outcomes in patients with heart failure. Researchers need to consider these methodological issues when measuring comorbidities in patients with heart failure. Further efforts are needed to develop guidelines on how to choose proper measures for comorbidities.

Treatment burden in multiple long-term conditions: a mixed-methods study protocol

BACKGROUND

Treatment burden represents the work patients undertake because of their health care, and the impact of that effort on the patient. Most research has focused on older adults (aged >65 years) with multiple long-term conditions (multimorbidity) (MLTC-M), but there are now more younger adults (aged 18-65 years) living with MLTC-M and they may experience treatment burden differently. Understanding experiences of treatment burden, and identifying those most at risk of high treatment burden, are important for designing primary care services to meet their needs.

AIM

To understand the treatment burden associated with MLTC-M, for people aged 18-65 years, and how primary care services affect this burden.

DESIGN & SETTING

Mixed-methods study in up to 33 primary care practices in two UK regions.

METHOD

The following two approaches will be used: (i) in-depth qualitative interviews with adults living with MLTC-M (approximately 40 participants) to understand their experiences of treatment burden and the impact of primary care, with a think-aloud aspect to explore face validity of a novel short treatment burden questionnaire (STBQ) for routine clinical use in the initial 15 interviews; (ii) cross-sectional patient survey (approximately 1000 participants), with linked routine medical record data to examine the factors associated with treatment burden for people living with MLTC-M, and to test the validity of STBQ.

CONCLUSION

This study will generate in-depth understanding of the treatment burden experienced by people aged 18-65 years living with MLTC-M, and how primary care services affect this burden. This will inform further development and testing of interventions to reduce treatment burden, and potentially influence MLTC-M trajectories and improve health outcomes.

Caring for high-need patients

OBJECTIVE

We aimed to explore the construct of "high need" and identify common need domains among high-need patients, their care professionals, and healthcare organizations; and to describe the interventions that health care systems use to address these needs, including exploring the potential unintended consequences of interventions.

METHODS

We conducted a modified Delphi panel informed by an environmental scan. Expert stakeholders included patients, interdisciplinary healthcare practitioners (physicians, social workers, peer navigators), implementation scientists, and policy makers. The environmental scan used a rapid literature review and semi-structured interviews with key informants who provide healthcare for high-need patients. We convened a day-long virtual panel meeting, preceded and followed by online surveys to establish consensus.

RESULTS

The environmental scan identified 46 systematic reviews on high-need patients, 19 empirical studies documenting needs, 14 intervention taxonomies, and 9 studies providing construct validity for the concept "high need." Panelists explored the construct and terminology and established that individual patients' needs are unique, but areas of commonality exist across all high-need patients. Panelists agreed on 11 domains describing patient (e.g., social circumstances), 5 care professional (e.g., communication), and 8 organizational (e.g., staffing arrangements) needs. Panelists developed a taxonomy of interventions with 15 categories (e.g., care navigation, care coordination, identification and monitoring) directed at patients, care professionals, or the organization. The project identified potentially unintended consequences of interventions for high-need patients, including high costs incurred for patients, increased time and effort for care professionals, and identification of needs without resources to respond appropriately.

CONCLUSIONS

Care for high-need patients requires a thoughtful approach; differentiating need domains provides multiple entry points for interventions directed at patients, care professionals, and organizations. Implementation efforts should consider outlined intended and unintended downstream effects on patients, care professionals, and organizations.

Prevalence and predictors of polypharmacy among community-based individuals with traumatic spinal cord injury

OBJECTIVES

The objective of this study was to investigate the rate of polypharmacy and predictors in community-living people with traumatic spinal cord injury (TSCI).

DESIGN

Cross-sectional study.

SETTING

Outpatient clinic of the rehabilitation hospital.

PARTICIPANTS

Seventy-five patients with TSCI ≥ 12 months were included in this study.

ASSESSMENTS

Demographic features were noted. American Spinal Injury Association Impairment Scale (AIS) was used to measure the neurological injury severity. Functional status was evaluated by Spinal Cord Independence Measure (SCIM) III. The Cumulative Illness Rating Scale (CIRS) was used to determine the comorbidities. Daily drug use ≥5 was considered to be polypharmacy.

RESULTS

The mean age was 41.3 ± 16.1 years. The mean injury duration was 55.5 ± 51.6 months. Thirty-nine (52%) patients were married, while 36 (48%) lived alone. The mean body mass index (BMI) was 25.4 ± 5.1 kg/m². AIS upper and lower extremity motor scores were 45.5 ± 11.1 and 10.3 ± 15.8, respectively. The mean SCIM III score was 56.4 ± 18.8. The mean system involvement number measured by CIRS was 5.2 ± 1.7. Fifty-two (70%) patients were motor complete, while 23 (30%) were motor incomplete. Thirty-eight (50.7%) patients had falls, 28 (37.3%) had car accidents, 6 (8%) had violence, and 3 (4%) had sports-related accidents. The rate of falling history in the last 6 months was 16% (12 patients). Polypharmacy was found in 38 (50.7%) patients. The predictors of the polypharmacy, according to the Regression analysis, were complete injury (Exp (B) i.e. Odds ratio = 7.491), advancing age (Odds ratio = 1.061) and injury duration (Odds ratio = 1.020).

CONCLUSION

In this study, more than half of the patients with chronic traumatic SCI had polypharmacy. The predictors of polypharmacy were completeness, advancing age, and longer injury duration.

Multimorbidity and the use of health services in the Brazilian population: National Health Survey 2019

OBJECTIVE

To describe the prevalence of health service use due to multimorbidity according to sociodemographic and health characteristics of the Brazilian population; to analyze the relationship between multimorbidity and the use of health services.

METHODS

This was a cross-sectional study using data from the 2019 National Health Survey. The outcomes were seeking health services in the last 15 days, medical consultation and hospitalization in the previous 12 months. Multimorbidity was defined as ≥ 2 chronic diseases. Associations were assessed using Poisson regression.

RESULTS

Of the 81,768 individuals, prevalence of seeking health services among individuals with multimorbidity was 38.0% higher (95%CI 1.31;1.45), medical appointments, 11.0% higher (95%CI 1.10;1.12), and 56.0% higher for hospitalizations (95%CI 1.44;1.70), compared to those without multimorbidity. This relationship was higher for seeking health services and medical appointments among male.

CONCLUSION

The use of health services was higher among those with multimorbidity, but different between the types of health services used and sexes.

MAIN RESULTS

Having multimorbidity increased the use of health services, even after progressive adjustment by sociodemographic characteristics and health needs. This relationship was greater among males for medical consultations.

IMPLICATIONS FOR SERVICES

Greater use of health services by individuals with multiple non-communicable diseases (NCDs) points to the need for changes in care models, with focus on continuity of care.

PERSPECTIVES

Health services should focus on continuous, coordinated and comprehensive approaches to the care of people with multimorbidity, thus seeking to increase the efficiency and quality of care provided to this population.

Factors Associated With Emergency Department Visits Among Patients Receiving Publicly-Funded Homecare Services: A Retrospective Chart Review From Southern Taiwan Regional Hospital

BACKGROUND

The public health strategy of increasing access to comprehensive home or community-based healthcare services and emergency home visits is intent on reducing the overcrowding of emergency departments. However, scientific evidence regarding the association between home-based healthcare services and emergency department uses is surprisingly insufficient and controversial so far. The present retrospective study identified the risk factors for emergency department visits among patients receiving publicly-funded homecare services.

METHODS

The personal demographic and medical information, caregiver characteristics, and behaviours related to homecare services and emergency department visits from the medical records and structured questionnaires of 108 patients who were recipients of integrated homecare services in a regional hospital in southern Taiwan between January 1, 2020, and December 31, 2020, were collected. After screening the potential predictor variables using the preliminary univariate analyses, the multivariate logistic regression with best subset selection approach was conducted to identify best combination of determinants to predict unplanned emergency department utilizations.

RESULTS

Best subset selection regression analysis showed Charlson Comorbidity Index (odds ratio (OR)=1.33, 95% CI=1.05 to 1.70), male caregiver (OR=0.18, 95% CI=0.05 to 0.66), duration of introducing homecare services (OR=0.97, 95% CI=0.95 to 1.00), working experience of dedicated nurses (OR=0.89, 95% CI=0.79 to 0.99) and number of emergency department utilizations within previous past year before enrollment (OR=1.54, 95% CI=1.14 to 2.10) as significant determinants for unplanned emergency department visits.

CONCLUSIONS

The present evidence may help government agencies propose supportive policies to improve access to integrated homecare resources and promote appropriate care recommendations to reduce unplanned or nonurgent emergency department visits among patients receiving homecare services.

Chronic Stress and Latent Virus Reactivation: Effects on Immune Aging, Chronic Disease Morbidity, and Mortality

OBJECTIVES

Social stress has been shown to affect immune functioning. Past research has found that chronic social stress and latent viral infections accelerate immune aging, leading to chronic disease morbidity and mortality. Chronic stress may also reactivate latent viral infections, like cytomegalovirus (CMV), accelerating the aging of the immune system.

METHOD

Utilizing panel survey data from 8,995 U.S. adults aged 56 or older from the Health and Retirement Study, this study investigates whether chronic stress interacts with CMV positivity to drive aging of the immune system, multimorbidity, and mortality.

RESULTS

Results of moderated mediation analysis indicate that the effect of CMV positivity on morbidity and mortality as mediated by immune aging indicators is amplified by chronic stress.

DISCUSSION

These findings suggest that immune aging is a biological pathway underlying the stress process and help explain past findings in the literature on stress and health.

Reynolds N, R. Barnes M, Hull S, Finer S, Mathur R. Ethnic differences in early onset multimorbidity and associations with health service use, long-term prescribing, years of life lost, and mortality: A cross-sectional study using clustering in the UK Clinical Practice Research Datalink

BACKGROUND

The population prevalence of multimorbidity (the existence of at least 2 or more long-term conditions [LTCs] in an individual) is increasing among young adults, particularly in minority ethnic groups and individuals living in socioeconomically deprived areas. In this study, we applied a data-driven approach to identify clusters of individuals who had an early onset multimorbidity in an ethnically and socioeconomically diverse population. We identified associations between clusters and a range of health outcomes.

METHODS AND FINDINGS

Using linked primary and secondary care data from the Clinical Practice Research Datalink GOLD (CPRD GOLD), we conducted a cross-sectional study of 837,869 individuals with early onset multimorbidity (aged between 16 and 39 years old when the second LTC was recorded) registered with an English general practice between 2010 and 2020. The study population included 777,906 people of White ethnicity (93%), 33,915 people of South Asian ethnicity (4%), and 26,048 people of Black African/Caribbean ethnicity (3%). A total of 204 LTCs were considered. Latent class analysis stratified by ethnicity identified 4 clusters of multimorbidity in White groups and 3 clusters in South Asian and Black groups. We found that early onset multimorbidity was more common among South Asian (59%, 33,915) and Black (56% 26,048) groups compared to the White population (42%, 777,906). Latent class analysis revealed physical and mental health conditions that were common across all ethnic groups (i.e., hypertension, depression, and painful conditions). However, each ethnic group also presented exclusive LTCs and different sociodemographic profiles: In White groups, the cluster with the highest rates/odds of the outcomes was predominantly male (54%, 44,150) and more socioeconomically deprived than the cluster with the lowest rates/odds of the outcomes. On the other hand, South Asian and Black groups were more socioeconomically deprived than White groups, with a consistent deprivation gradient across all multimorbidity clusters. At the end of the study, 4% (34,922) of the White early onset multimorbidity population had died compared to 2% of the South Asian and Black early onset multimorbidity populations (535 and 570, respectively); however, the latter groups died younger and lost more years of life. The 3 ethnic groups each displayed a cluster of individuals with increased rates of primary care consultations, hospitalisations, long-term prescribing, and odds of mortality. Study limitations include the exclusion of individuals with missing ethnicity information, the age of diagnosis not reflecting the actual age of onset, and the exclusion of people from Mixed, Chinese, and other ethnic groups due to insufficient power to investigate associations between multimorbidity and health-related outcomes in these groups.

CONCLUSIONS

These findings emphasise the need to identify, prevent, and manage multimorbidity early in the life course. Our work provides additional insights into the excess burden of early onset multimorbidity in those from socioeconomically deprived and diverse groups who are disproportionately and more severely affected by multimorbidity and highlights the need to ensure healthcare improvements are equitable.

Towards a personalized health care using a divisive hierarchical clustering approach for comorbidity and the prediction of conditioned group risks

The objective was to assess risk of hospitalization and mortality of comorbidities using divisive hierarchical risk clustering to advice clinical interventions. Subjects and Methods: Data from the EHR of a general population, 3799885 adults, followed by 5 years. Model were performed using Spark and Scikit-learn and accuracy for the models was analyzed. Results: The number of models generated depends in part on the number of chronic diseases included (ex testing a sample of six diseases, a total number of 397 models for all-cause mortality and 431 models for hospitalization). The estimated models offered an ordered selection for the relevant clinical variables and their estimated risk as a group and for the individual patient in the group. Accuracy was assessed according to age, sex and the cardinality of the comorbid groups. A mobile version and dashboard were developed. Conclusion: The software developed stratified hospital admission and mortality risk in clusters of chronic diseases, and for a given patient, it could advise intensifying treatment or reallocating the patient risk.

Vertical integration of general practices with acute hospitals in England: rapid impact evaluation

Background

Vertical integration means merging organisations that operate at different stages along the patient pathway. We focus on acute hospitals running primary care medical practices. Evidence is scarce concerning the impact on use of health-care services and patient experience.

Objectives

To assess the impact of vertical integration on use of hospital services, service delivery and patient experience and whether patients with multiple long-term conditions are affected differently from others.

Design

Rapid, mixed methods evaluation with four work packages: (1) review of NHS trust annual reports and other sources to understand the scale of vertical integration across England; (2) development of the statistical analysis; (3) analysis of national survey data on patient experience, and national data on use of hospital services over the 2 years preceding and following vertical integration, comparing vertically integrated practices with a variety of control practices; and (4) focus groups and interviews with staff and patients across three case study sites to explore the impact of vertical integration on patient experience of care.

Results

At 31 March 2021, 26 NHS trusts were in vertically integrated organisations, running 85 general practices across 116 practice sites. The earliest vertical integration between trusts and general practices was in 2015; a mean of 3.3 practices run by each trust (range 1-12). On average, integrated practices have fewer patients, are slightly more likely to be in the most deprived decile of areas, are more likely to hold an alternative provider medical services contract and have worse Quality and Outcomes Framework scores compared with non-integrated practices. Vertical integration is associated with statistically significant, modest reductions in rates of accident and emergency department attendances: 2% reduction (incidence rate ratio 0.98, 95% confidence interval 0.96 to 0.99; p < 0.0001); outpatient attendances: 1% reduction (incidence rate ratio 0.99, 95% confidence interval 0.99 to 1.00; p = 0.0061), emergency inpatient admissions: 3% reduction (incidence rate ratio 0.97, 95% confidence interval 0.95 to 0.99; p = 0.0062) and emergency readmissions: 5% reduction (incidence rate ratio 0.95, 95% confidence interval 0.91 to 1.00; p = 0.039), with no impact on length of stay, overall inpatient admissions or inpatient admissions for ambulatory care sensitive conditions. The falls in accident and emergency department and outpatient attendance rates are temporary. Focus groups and interviews with staff (N = 22) and interviews with patients (N = 14) showed that with vertical integration, health service improvements are introduced following a period of cultural interchange. Patients with multiple long-term conditions continue to encounter 'navigation work' choosing and accessing health-care provision, with diminishing continuity of care.

Limitations

In the quantitative analysis, we could not replicate the counterfactual of what would have happened in those specific locations had practices not merged with trusts. There was imbalance across three case study sites with regard to staff and patients recruited for interview, and the latter were drawn from patient participation groups who may not be representative of local populations.

Conclusions

Vertical integration can lead to modest reductions in use of hospital services and has minor or no impact on patient experience of care. Our analysis does not reveal a case for widespread roll-out of the approach.

Future research

Further quantitative follow-up of the longer-term impact of vertical integration on hospital usage and more extensive interviewing of patients and their carers about patient experiences of navigating care.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (BRACE Project no. 16/138/31) and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 17. See the NIHR Journals Library website for further project information.

What's the low back pain problem represented to be? An analysis of discourse of the Australian policy directives

PURPOSE

Low back pain (LBP) directives provide information about how LBP should be managed, communicated and navigated in complex health systems, making them an important form of policy. This study aimed to examine how LBP is problematised (represented) in Australian directives.

MATERIALS AND METHODS

We employed an analysis of discourse of LBP directives drawing on Bacchi's "What's the problem represented to be?" policy problematisation approach.

RESULTS

Our analysis suggests that LBP is problematised as a symptom that tends to improve when individuals take responsibility for themselves, but may require care at times. The way in which LBP is represented in the directives excludes important aspects, such as the uncertainties of scientific knowledge, paradigms other than (post)positivist, multimorbidity, social and structural determinants of health.

CONCLUSION

LBP directives may benefit from problematisations of LBP that consider the ongoing nature of LBP and broader contextual factors that impact on both LBP outcomes and care, beyond individual responsibility. Consideration of a wider range of paradigms and expanded evidence base may also be beneficial, as these are likely to enable individuals, clinicians and the Australian healthcare system to address LBP while dealing with its complexities, enabling real-world changes to lessen the LBP burden.IMPLICATIONS FOR REHABILITATIONHealthcare professionals who work with people who experience low back pain (LBP) may benefit from critically reflecting about discourses embedded in policy directives.Healthcare professionals may consider engaging in policy changes processes to expand the discourses on which LBP policy directives rely.Healthcare professionals' ability to enact policy recommendations may be enhanced by consideration of the fluctuating nature of LBP, uncertainties, multimorbidity and determinants of health.

ESPEN guideline on nutritional support for polymorbid medical inpatients

BACKGROUND

Disease-related malnutrition in polymorbid medical inpatients is a highly prevalent syndrome associated with significantly increased morbidity, disability, short- and long-term mortality, impaired recovery from illness, and cost of care.

AIM

As there are uncertainties in applying disease-specific guidelines to patients with multiple conditions, our aim was to provide evidence-based recommendations on nutritional support for the polymorbid patient population hospitalized in medical wards.

METHODS

This update adheres to the standard operating procedures for ESPEN guidelines. We did a systematic literature search for 15 clinical questions in three different databases (Medline, Embase and the Cochrane Library), as well as in secondary sources (e.g. published guidelines), until July 12th. Retrieved abstracts were screened to identify relevant studies that were used to develop recommendations (incl. SIGN grading), which was followed by submission to Delphi voting.

RESULTS

From a total of 3527 retrieved abstracts, 60 new relevant studies were analyzed and used to generate a guideline draft that proposed 32 recommendations (7x A, 11x B, 10x O and 4x GPP), which encompass different aspects of nutritional support including indication, route of feeding, energy and protein requirements, micronutrient requirements, disease-specific nutrients, timing, monitoring and procedure of intervention. The results of the first online voting showed a strong consensus (agreement of >90%) on 100% of the recommendations. Therefore, no final consensus conference was needed.

CONCLUSIONS

Recent high-quality trials have provided increasing evidence that nutritional support can reduce morbidity and other complications associated with malnutrition in polymorbid patients. The timely screening of patients for risk of malnutrition at hospital admission followed by individualized nutritional support interventions for at-risk patients should be part of routine clinical care and multimodal treatment in hospitals worldwide. Use of this updated guideline offers an evidence-based nutritional approach to the polymorbid medical inpatients and may improve their outcomes.

Managing medical and psychiatric multimorbidity in older patients

Aging increases susceptibility both to psychiatric and medical disorders through a variety of processes ranging from biochemical to pharmacologic to societal. Interactions between aging-related brain changes, emotional and psychological symptoms, and social factors contribute to multimorbidity - the presence of two or more chronic conditions in an individual - which requires a more patient-centered, holistic approach than used in traditional single-disease treatment guidelines. Optimal treatment of older adults with psychiatric and medical multimorbidity necessitates an appreciation and understanding of the links between biological, psychological, and social factors - including trauma and racism - that underlie physical and psychiatric multimorbidity in older adults, all of which are the topic of this review.

20-year trends in multimorbidity by race/ethnicity among hospitalized patient populations in the United States

BACKGROUND

The challenges presented by multimorbidity continue to rise in the United States. Little is known about how the relative contribution of individual chronic conditions to multimorbidity has changed over time, and how this varies by race/ethnicity. The objective of this study was to describe trends in multimorbidity by race/ethnicity, as well as to determine the differential contribution of individual chronic conditions to multimorbidity in hospitalized populations over a 20-year period within the United States.

METHODS

This is a serial cross-sectional study using the Nationwide Inpatient Sample (NIS) from 1993 to 2012. We identified all hospitalized patients aged ≥ 18 years old with available data on race/ethnicity. Multimorbidity was defined as the presence of 3 or more conditions based on the Elixhauser comorbidity index. The relative change in the proportion of hospitalized patients with multimorbidity, overall and by race/ethnicity (Black, White, Hispanic, Asian/Pacific Islander, Native American) were tabulated and presented graphically. Population attributable fractions were estimated from modified Poisson regression models adjusted for sex, age, and insurance type. These fractions were used to describe the relative contribution of individual chronic conditions to multimorbidity over time and across racial/ethnic groups.

RESULTS

There were 123,613,970 hospitalizations captured within the NIS between 1993 and 2012. The prevalence of multimorbidity increased in all race/ethnic groups over the 20-year period, most notably among White, Black, and Native American populations (+ 29.4%, + 29.7%, and + 32.0%, respectively). In both 1993 and 2012, Black hospitalized patients had a higher prevalence of multimorbidity (25.1% and 54.8%, respectively) compared to all other race/ethnic groups. Native American populations exhibited the largest overall increase in multimorbidity (+ 32.0%). Furthermore, the contribution of metabolic diseases to multimorbidity increased, particularly among Hispanic patients who had the highest population attributable fraction values for diabetes without complications (15.0%), diabetes with complications (5.1%), and obesity (5.8%).

CONCLUSIONS

From 1993 to 2012, the secular increases in the prevalence of multimorbidity as well as changes in the differential contribution of individual chronic conditions has varied substantially by race/ethnicity. These findings further elucidate the racial/ethnic gaps prevalent in multimorbidity within the United States.

PRIOR PRESENTATIONS

Preliminary finding of this study were presented at the Society of General Internal Medicine (SGIM) Annual Conference, Washington, DC, April 21, 2017.

Understanding multimorbidity requires sign-disease networks and higher-order interactions, a perspective

Background

Count scores, disease clustering, and pairwise associations between diseases remain ubiquitous in multimorbidity research despite two major shortcomings: they yield no insight into plausible mechanisms underlying multimorbidity, and they ignore higher-order interactions such as effect modification.

Objectives

We argue that two components are currently missing but vital to develop novel multimorbidity metrics. Firstly, networks should be constructed which consists simultaneously of signs, symptoms, and diseases, since only then could they yield insight into plausible shared biological mechanisms underlying diseases.Secondly, learning pairwise associations is insufficient to fully characterize the correlations in a system. That is, synergistic (e.g., cooperative or antagonistic) effects are widespread in complex systems, where two or more elements combined give a larger or smaller effect than the sum of their individual effects. It can even occur that pairs of symptoms have no pairwise associations whatsoever, but in combination have a significant association. Therefore, higher-order interactions should be included in networks used to study multimorbidity, resulting in so-called hypergraphs.

Methods

We illustrate our argument using a synthetic Bayesian Network model of symptoms, signs and diseases, composed of pairwise and higher-order interactions. We simulate network interventions on both individual and population levels and compare the ground-truth outcomes with the predictions from pairwise associations.

Conclusion

We find that, when judged purely from the pairwise associations, interventions can have unexpected 'side-effects' or the most opportune intervention could be missed. The hypergraph uncovers links missed in pairwise networks, giving a more complete overview of sign and disease associations.

Defining Multimorbidity in Older Patients Hospitalized with Medical Conditions

BACKGROUND

The term "multimorbidity" identifies high-risk, complex patients and is conventionally defined as ≥2 comorbidities. However, this labels almost all older patients as multimorbid, making this definition less useful for physicians, hospitals, and policymakers.

OBJECTIVE

Develop new medical condition-specific multimorbidity definitions for patients admitted with acute myocardial infarction (AMI), heart failure (HF), and pneumonia patients. We developed three medical condition-specific multimorbidity definitions as the presence of single, double, or triple combinations of comorbidities - called Qualifying Comorbidity Sets (QCSs) - associated with at least doubling the risk of 30-day mortality for AMI and pneumonia, or one-and-a-half times for HF patients, compared to typical patients with these conditions.

DESIGN

Cohort-based matching study PARTICIPANTS: One hundred percent Medicare Fee-for-Service beneficiaries with inpatient admissions between 2016 and 2019 for AMI, HF, and pneumonia.

MAIN MEASURES

Thirty-day all-location mortality KEY RESULTS: We defined multimorbidity as the presence of ≥1 QCS. The new definitions labeled fewer patients as multimorbid with a much higher risk of death compared to the conventional definition (≥2 comorbidities). The proportions of patients labeled as multimorbid using the new definition versus the conventional definition were: for AMI 47% versus 87% (p value<0.0001), HF 53% versus 98% (p value<0.0001), and pneumonia 57% versus 91% (p value<0.0001). Thirty-day mortality was higher among patients with ≥1 QCS compared to ≥2 comorbidities: for AMI 15.0% versus 9.5% (p<0.0001), HF 9.9% versus 7.0% (p <0.0001), and pneumonia 18.4% versus 13.2% (p <0.0001).

CONCLUSION

The presence of ≥2 comorbidities identified almost all patients as multimorbid. In contrast, our new QCS-based definitions selected more specific combinations of comorbidities associated with substantial excess risk in older patients admitted for AMI, HF, and pneumonia. Thus, our new definitions offer a better approach to identifying multimorbid patients, allowing physicians, hospitals, and policymakers to more effectively use such information to consider focused interventions for these vulnerable patients.

Adjusted morbidity groups and survival: a retrospective cohort study of primary care patients with chronic conditions

BACKGROUND

Chronic conditions are one of the main determinants of frailty, functional disability, loss of quality of life and the number one cause of death worldwide. This study aimed to describe the survival of patients with chronic conditions who were followed up in primary care according to the level of risk by adjusted morbidity groups and to analyse the effects of sex, age, clinician and care factors on survival.

METHODS

This was a longitudinal observational study of a retrospective cohort of patients with chronic conditions identified by the adjusted morbidity group stratifier of the electronic medical records in a primary health centre of the Region of Madrid, which has an assigned population of 18,107 inhabitants. The follow-up period was from June 2015 to June 2018. A description of survival according to the Kaplan-Meier method and Cox proportional hazards multivariate regression model was used to analyse the effects of sex, age, clinician and care factors.

RESULTS

A total of 9,866 patients with chronic conditions were identified; 77.4% (7,638) had a low risk, 18.1% (1,784) had a medium risk, and 4.5% (444) had a high risk according to the adjusted morbidity groups. A total of 477 patients with chronic conditions died (4.8%). The median survival was 36 months. The factors associated with lower survival were age over 65 years (hazard ratio [HR] = 1.3; 95% confidence interval [CI] = 1.1-1.6), receiving palliative care (HR = 3.4; 95% CI = 2.6-4.5), high versus low risk level (HR = 2.4; 95% CI = 1.60-3.7), five chronic conditions or more (HR = 1.5; 95% CI = 1.2-2), complexity index (HR = 1.01; 95% CI = 1.02-1.04) and polymedication (HR = 2.6; 95% CI = 2.0-3.3).

CONCLUSIONS

There was a gradual and significant decrease in the survival of patients with chronic conditions according to their level of risk as defined by adjusted morbidity groups. Other factors, such as older age, receiving palliative care, high number of chronic conditions, complexity, and polymedication, had a negative effect on survival. The adjusted morbidity groups are useful in explaining survival outcomes and may be valuable for clinical practice, resource planning and public health research.

Insomnia Impairs Both the Pro-BDNF and the BDNF Levels Similarly to Older Adults with Cognitive Decline: An Exploratory Study

Sleep disorders, including insomnia, are common during aging, and these conditions have been associated with cognitive decline in older adults. Moreover, during the aging process, neurotransmitters, neurohormones, and neurotrophins decrease significantly, leading to the impairment of cognitive functions. In this sense, BDNF, the most abundant neurotrophic factor in the human brain, has been suggested as a potential target for the prevention and improvement of cognitive decline during aging; however, the current evidence demonstrates that the exogenous administration of BDNF does not improve cognitive function. Hence, in the present study, we quantified pro-BDNF (inactive) and BDNF (active) concentrations in serum samples derived from older individuals with insomnia and/or cognitive decline. We used linear regression to analyze whether clinical or sociodemographic variables impacted the levels of BNDF concentration. We observed that insomnia, rather than cognitive decline, is significantly associated with BDNF concentration, and these effects are independent of other variables. To our knowledge, this is the first study that points to the impact of insomnia on improving the levels of BDNF during aging and suggests that opportune treatment of insomnia may be more beneficial to prevent cognitive decline during aging.

Caregivers' Self-Rated General Health, Physical and Mental Health Status, Disease Morbidity and Association with Uncontrolled Asthma in Children

This study examined the association between caregivers' self-rated general health, poor physical/mental health days, disease morbidity and asthma control in children from the United States with current asthma. The data analyzed for this study were obtained from 7522 children aged 0-17 years who participated in the 2012-2014, 2015-2017, 2018, and 2019 cycles of the Behavioral Risk Factor Surveillance System Asthma Call-back Survey (ACBS). We employed univariate analysis to describe the study population and weighted binary logistic regression to examine the association of predictors with asthma control. Approximately 50% of the children had uncontrolled asthma. The results show that caregivers who reported fair general health had a 61% higher likelihood of reporting uncontrolled asthma in their children compared to those who reported good/very good/excellent health (adjusted odds ratio [aOR] = 1.61; 95% confidence interval [CI], 1.14-2.26). Poor caregiver general health did not reach statistical significance in predicting uncontrolled asthma (aOR = 1.05, 95% CI, 0.62-1.75). Furthermore, having 1 to 14 poor physical/mental health days ([aOR] = 1.70; 95% CI, 1.28-2.227) and ≥15 poor physical/mental health days (aOR = 1.82, 95% CI, 1.31-2.53) was predictive of uncontrolled asthma in children. Additionally, endorsing one reported disease (aOR = 1.49, 95% CI, 1.15-1.93) and ≥2 diseases (aOR = 1.38, 95% CI, 1.08-1.78) was associated with uncontrolled child asthma. These findings underscore the association between caregivers' self-reported general health, poor mental/physical health days, disease morbidity and uncontrolled asthma among children from the U.S. with asthma. Pediatricians and child health practitioners should recall the importance of this relationship. To facilitate the identification of caregivers at risk and provide more comprehensive and effective care for children with asthma, healthcare practitioners should utilize every child asthma care encounter to inquire about the overall health of caregivers.

Adverse childhood experiences and the development of multimorbidity across adulthood-a national 70-year cohort study

AIM

To examine impact of adverse childhood experiences (ACE) on rates and development of multimorbidity across three decades in adulthood.

METHODS

Sample: Participants from the 1946 National Survey of Health and Development, who attended the age 36 assessment in 1982 and follow-up assessments (ages 43, 53, 63, 69; N = 3,264, 51% males). Prospectively collected data on nine ACEs was grouped into (i) psychosocial, (ii) parental health and (iii) childhood health. For each group, we calculated cumulative ACE scores, categorised into 0, 1 and ≥2 ACEs. Multimorbidity was estimated as the total score of 18 health disorders.Serial cross-sectional linear regression was used to estimate associations between grouped ACEs and multimorbidity during follow-up. Longitudinal analysis of ACE-associated changes in multimorbidity trajectories across follow-up was estimated using linear mixed-effects modelling for ACE groups (adjusted for sex and childhood socioeconomic circumstances).

FINDINGS

Accumulation of psychosocial and childhood health ACEs were associated with progressively higher multimorbidity scores throughout follow-up. For example, those with ≥2 psychosocial ACEs experienced 0.20(95% CI 0.07, 0.34) more disorders at age 36 than those with none, rising to 0.61(0.18, 1.04) disorders at age 69.All three grouped ACEs were associated with greater rates of accumulation and higher multimorbidity trajectories across adulthood. For example, individuals with ≥2 psychosocial ACEs developed 0.13(-0.09, 0.34) more disorders between ages 36 and 43, 0.29(0.06, 0.52) disorders between ages 53 and 63, and 0.30(0.09, 0.52) disorders between ages 63 and 69 compared with no psychosocial ACEs.

INTERPRETATIONS

ACEs are associated with widening inequalities in multimorbidity development in adulthood and early old age. Public health policies should aim to reduce these disparities through individual and population-level interventions.

Factors Associated with the Use of Complementary and Alternative Medicine/Therapy among United States Adults with Asthma

This article examined the sociodemographic and health-related factors associated with the use of complementary and alternative medicine/therapy (CAM) among adults with current asthma in the United States. We used data from 76,802 adults aged 18 years and above from the 2012-2019 Behavioral Risk Factor Surveillance System (BRFSS) Asthma Call-back Survey (ACBS) cycles. Weighted binary and multinomial logistic regression was used to examine the association of these factors with ever CAM use and the number of CAM use. We found that approximately 45.2% of US adults with asthma ever used CAM. Among adults with asthma, 25.3% and 19.9% endorsed using one CAM and ≥2 CAMs, respectively. CAM use was significantly associated with adults ≤ 35 years, female gender, multiple/other race/ethnicity, higher cost barriers, adults with two or more disease comorbidities, and those with poorly controlled asthma in both binary and multinomial models. CAM use was not associated with insurance and income status. Understanding factors associated with CAM use can provide asthma care professionals valuable insights into the underlying drivers of CAM use behavior in this population, enabling them to offer more informed and effective medical advice and guidance.

Social determinants of multimorbidity patterns: A systematic review

Social determinants of multimorbidity are poorly understood in clinical practice. This review aims to characterize the different multimorbidity patterns described in the literature while identifying the social and behavioral determinants that may affect their emergence and subsequent evolution. We searched PubMed, Embase, Scopus, Web of Science, Ovid MEDLINE, CINAHL Complete, PsycINFO and Google Scholar. In total, 97 studies were chosen from the 48,044 identified. Cardiometabolic, musculoskeletal, mental, and respiratory patterns were the most prevalent. Cardiometabolic multimorbidity profiles were common among men with low socioeconomic status, while musculoskeletal, mental and complex patterns were found to be more prevalent among women. Alcohol consumption and smoking increased the risk of multimorbidity, especially in men. While the association of multimorbidity with lower socioeconomic status is evident, patterns of mild multimorbidity, mental and respiratory related to middle and high socioeconomic status are also observed. The findings of the present review point to the need for further studies addressing the impact of multimorbidity and its social determinants in population groups where this problem remains invisible (e.g., women, children, adolescents and young adults, ethnic groups, disabled population, older people living alone and/or with few social relations), as well as further work with more heterogeneous samples (i.e., not only focusing on older people) and using more robust methodologies for better classification and subsequent understanding of multimorbidity patterns. Besides, more studies focusing on the social determinants of multimorbidity and its inequalities are urgently needed in low- and middle-income countries, where this problem is currently understudied.

Uncertainty in low back pain care - insights from an ethnographic study

PURPOSE

To explore how uncertainty plays out in low back pain (LBP) care and investigate how clinicians manage accompanying emotions/tensions.

MATERIALS AND METHODS

We conducted ethnographic observations of clinical encounters in a private physiotherapy practice and a public multidisciplinary pain clinic. Our qualitative reflexive thematic analysis involved abductive thematic principles informed by Fox and Katz (medical uncertainty) and Ahmed (emotions).

RESULTS

We identified three themes. (1) Sources of uncertainty: both patients and clinicians expressed uncertainty during clinical encounters (e.g., causes of LBP, mismatch between imaging findings and presentation). Such uncertainty was often accompanied by emotions - anger, tiredness, frustration. (2) Neglecting complexity: clinicians often attempted to decrease uncertainty and associated emotions by providing narrow answers to questions about LBP. At times, clinicians' denial of uncertainty also appeared to deny patients the right to make informed decisions about treatments. (3) Attending to uncertainty?: clinicians attended to uncertainty through logical reasoning, reassurance, acknowledgement, personalising care, shifting power, adjusting language and disclosing risks.

CONCLUSIONS

Uncertainty pervades LBP care and is often accompanied by emotions, emphasising the need for a healthcare culture that recognises the emotional dimensions of patient-clinician interactions and prepares clinicians and patients to be more accepting of, and clearly communicate about, uncertainty.IMPLICATIONS FOR REHABILITATIONUncertainty pervades LBP care and is often accompanied by emotions.Neglecting complexity in LBP care may compromise person-centred care.Acknowledging uncertainty can enhance communication, balance patient-clinician relationships and address human aspects of care.

Evidence-Based Medicine: History, Review, Criticisms, and Pitfalls

Evidence-based medicine (EBM) is the use of high-quality clinical research in making decisions about the care of patients. Its formal origin dates back to the mid-nineteenth century, and since then, it has continued to evolve. The best research evidence, clinical expertise, and patient values are described as the foundations of EBM. However, several tools and skills have been developed and added over time. EBM has faced a lot of criticism, and the pitfalls are widely discussed and published in the medical literature. The biggest challenge is the changing paradigm of healthcare, cost-effectiveness, and changing evidence which has led to controversies and challenges in the rapid adaptation of the EBM. This review article discusses the history, conception, and evolution of modern-day EBM. In addition, we discuss why EBM has been criticized and highlight the pitfalls.

Multimorbidity prevalence and patterns in chronic kidney disease: findings from an observational multicentre UK cohort study

PURPOSE

Multimorbidity [defined as two or more long-term conditions (LTCs)] contributes to increased treatment and medication burden, poor health-related quality of life, and worse outcomes. Management strategies need to be patient centred and tailored depending on existing comorbidities; however, little is known about the prevalence and patterns of comorbidities in people with chronic kidney disease (CKD). We investigated the prevalence of multimorbidity and comorbidity patterns across all CKD stages.

METHODS

Multimorbidity was assessed, using a composite of self-report and clinical data, across four CKD groups stratified by eGFR [stage 1-2, stage 3a&b, stage 4-5, and kidney transplant (KTx)]. Principal component analysis using varimax rotation was used to identify comorbidity clusters across each group.

RESULTS

Of the 978 participants (mean 66.3 ± 14 years, 60% male), 96.0% had multimorbidity. In addition to CKD, the mean number of comorbidities was 3.0 ± 1.7. Complex multimorbidity (i.e. ≥ 4 multiple LTCs) was identified in 560 (57.3%) participants. When stratified by CKD stage, the two most prevalent comorbidities across all stages were hypertension (> 55%) and musculoskeletal disorders (> 40%). The next most prevalent comorbidity for CKD stages 1-2 was lung conditions and for CKD stages 3 and 4-5 it was heart problems. CKD stages 1-2 showed different comorbidity patterns and clustering compared to other CKD stages.

CONCLUSION

Most people across the spectrum of CKD have multimorbidity. Different patterns of multimorbidity exist at different stages of CKD, and as such, clinicians should consider patient comorbidities to integrate care and provide effective treatment strategies.

Health care utilization and potentially preventable adverse outcomes of high-need, high-cost middle-aged and older adults: Needs for integrated care models with life-course approach

PURPOSE OF THE RESEARCH

The success of modern health care increases life expectancy and prolongs the days of having multimorbidity and functional limitations; the so-defined "high need, high cost (HNHC)" state represents the extreme scenarios of care burden and complexity. This study aims to explore health care utilization and the risk of preventable adverse outcomes stratified by age and HNHC state.

MATERIALS AND METHODS

We conducted a retrospective cohort study using the National Health Insurance (NHI) database. People aged ≥40 years were included and further stratified by age (middle-aged: 40-64 and older adults: 65) and HNHC state (top 10% of spending). Health care utilization and drug consumption across different groups were obtained. The multimorbidity frailty index (mFI) was developed for further analysis. Cox regression models were used to examine the associations between HNHC and adverse clinical outcomes (preventable hospitalizations, preventable emergency department visits, and mortality).

RESULTS

HNHC participants were older, had a higher mFI and drug consumption, and had higher health care utilization. Compared with non-HNHC participants, HNHC participants exhibited a 4.4-fold and 2.4-fold higher risk of preventable hospitalizations in middle-aged (HR=4.41; 95% CI, 4.17-4.65, p<0.01) and older adults (HR=2.44; 95% CI, 2.34-2.55, p<0.01). Similar risks were observed for preventable emergency department visits and mortality (all p<0.01).

CONCLUSIONS

The HNHC state substantially increased health care utilization, polypharmacy, and potentially preventable adverse outcomes after adjustment for frailty. Intervention studies developing integrated care models using the life-course approach are needed to improve the quality of health care systems in super-aged societies.

Clinical assessment and management of patients with multimorbidity

Internal medicine specialists, also known as general internal medicine specialists are specialist physicians trained to manage particularly complex or multisystem disease conditions that single-organ-disease specialists may not be trained to deal with. The management of multimorbidity, however, is often complex, and requires specific clinical skills and corresponding experience in appropriate diagnostic and therapeutic procedures. Multimorbidity is associated with a decline in many aspects of health and in consequence with an increase in hospital admissions, polypharmacy, and use of health care and social resouces. When prescribing medicine to patients with multimorbidity, all the risks and benefits, as well as possible interactions should be carefully considered. The prescription appropriateness can be assessed by validated tools like STOPP-START criteria. Beneficial part of good prescribing is deprescribing - planned and supervised process of dose reduction or withdrawal of medications that are no longer needed in the circumstances of the patient.

Patterns and Predictors of Multimorbidity in the Azar Cohort

BACKGROUND

The co-existence of chronic diseases (CDs), a condition defined as multimorbidity (MM), is becoming a major public health issue. Therefore, we aimed to determine the patterns and predictors of MM in the Azar Cohort.

METHODS

We evaluated the prevalence of MM in 15,006 (35-70-year old) subjects of the Azar Cohort Study. MM was defined as the co-existence of two or more CDs. Data on the subjects' socioeconomic status, demographics, sleeping habits, and physical activity were collected using questionnaires.

RESULTS

The overall prevalence of MM was 28.1%. The most prevalent CDs, in decreasing order, were obesity, hypertension, depression, and diabetes. Obesity, depression, and diabetes were the most co-occurring CDs. The MM risk increased significantly with age, illiteracy, and in females. Also, the subjects within the lowest tertile of physical activity level (OR=1.89; 95% CI: 1.75-2.05) showed higher MM risk than those with the highest level of physical activity. Findings regarding current smoking status indicated that being an ex-smoker or smoker of other types of tobacco significantly increased the risk of MM.

CONCLUSION

The reduction of MM is possible by promoting public health from an early age among people of various socioeconomic conditions. It is vital to offer the necessary health support to the aging population of Iran.

An analysis of socioeconomic factors on multiple chronic conditions and its economic burden: evidence from the National Health Service Survey in Yunnan Province, China

Background

The economic burden of multiple chronic conditions (MCCs) and its socio-economic influencing factors have widely raised public concerns. However, there are few large population-based studies on these problems in China. Our study aims at determining the economic burden of MCCs and associated factors specific to multimorbidity among middle-aged and older individuals.

Methods

As our study population, we extracted all 11,304 participants over 35 years old from the 2018 National Health Service Survey (NHSS) in Yunnan. Economic burden and socio-demographic characteristics were analyzed with descriptive statistics. Chi-square test and generalized estimating equations (GEE) regression models were used to identify influencing factors.

Results

The prevalence of chronic diseases was 35.93% in 11,304 participants and the prevalence of MCCs increased with age, was 10.12%. Residents who lived in rural areas were more likely to report MCCs than those who lived in urban areas (adjusted OR = 1.347, 97.5% CI: 1.116-1.626). Ethnic minority groups were less likely to report MCCs than those of Han (OR = 0.752, 97.5% CI: 0.601-0.942). Overweight or obese people were more likely to report MCCs than people with normal weight (OR = 1.317, 97.5% CI: 1.099-1.579). The per capita expenses of 2 weeks' illness, per capita hospitalization expenses, annual household income, annual household expenses, and annual household medical expenses of MCCs were ¥292.90 (±1427.80), ¥4804.22 (±11851.63), ¥51064.77 (±52158.76), ¥41933.50 (±39940.02) and ¥11724.94 (±11642.74), respectively. The per capita expenses of 2 weeks' illness, per capita hospitalization expenses, annual household income, annual household cost, and annual household medical expenses of hypertensive co-diabetic patients were more compared to those with other three comorbidity modes.

Conclusion

The prevalence of MCCs was relatively high among middle-aged and older individuals in Yunnan, China, which bought a heavy economic burden. This encourages policy makers and health providers to pay more attention to the behavioral/lifestyle factors, that contribute to multimorbidity to a great extent. Furthermore, health promotion and education in terms of MCCs need to be prioritized in Yunnan.

Development and validation of novel multimorbidity indices for older adults

BACKGROUND

Measuring multimorbidity in claims data is used for risk adjustment and identifying populations at high risk for adverse events. Multimorbidity indices such as Charlson and Elixhauser scores have important limitations. We sought to create a better method of measuring multimorbidity using claims data by incorporating geriatric conditions, markers of disease severity, and disease-disease interactions, and by tailoring measures to different outcomes.

METHODS

Health conditions were assessed using Medicare inpatient and outpatient claims from subjects age 67 and older in the Health and Retirement Study. Separate indices were developed for ADL decline, IADL decline, hospitalization, and death, each over 2 years of follow-up. We validated these indices using data from Medicare claims linked to the National Health and Aging Trends Study.

RESULTS

The development cohort included 5012 subjects with median age 76 years; 58% were female. Claims-based markers of disease severity and disease-disease interactions yielded minimal gains in predictive power and were not included in the final indices. In the validation cohort, after adjusting for age and sex, c-statistics for the new multimorbidity indices were 0.72 for ADL decline, 0.69 for IADL decline, 0.72 for hospitalization, and 0.77 for death. These c-statistics were 0.02-0.03 higher than c-statistics from Charlson and Elixhauser indices for predicting ADL decline, IADL decline, and hospitalization, and <0.01 higher for death (p < 0.05 for each outcome except death), and were similar to those from the CMS-HCC model. On decision curve analysis, the new indices provided minimal benefit compared with legacy approaches. C-statistics for both new and legacy indices varied substantially across derivation and validation cohorts.

CONCLUSIONS

A new series of claims-based multimorbidity measures were modestly better at predicting hospitalization and functional decline than several legacy indices, and no better at predicting death. There may be limited opportunity in claims data to measure multimorbidity better than older methods.

Prevalence of Multimorbidity in the Middle East: A Systematic Review of Observational Studies

BACKGROUND

There has not been a review that evaluated the prevalence of multimorbidity in the Middle East. This review aims to measure the prevalence, demographic factors, and consequences of multimorbidity in the Middle East region.

STUDY DESIGN

A quantitative systematic review includes cross-sectional and longitudinal cohort studies.

METHODS

The prevalence systematic review approach from the Joanna Briggs Institute was applied. We searched PsychINFO, MEDLINE, EMCARE, CINAHL, Scopus, Science Direct, and the Cochrane Central Register of Controlled Trials. Data were extracted methodically in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards. Studies written in English and released between 2012 and March 2022 were included. For the meta-analysis, a random-effects model was applied. PROSPERO registration number: CRD42022335534.

RESULTS

The final sample consisted of eight cohort and observational studies. The number of participants varied from 354 to 796,427. Multimorbidity was present in all populations with a prevalence of 21.8% (95% confidence interval (CI): 21.7-21.8%).

CONCLUSION

Multimorbidity affects a significant section of the world's population. A uniform operationalization of multimorbidity is required in the Middle East in order to enable reliable estimates of illness burden, effective disease management, and resource distribution.

Defining and measuring multimorbidity in primary care in Singapore: Results of an online Delphi study

Multimorbidity, common in the primary care setting, has diverse implications for both the patient and the healthcare system. However, there is no consensus on the definition of multimorbidity globally. Thus, we aimed to conduct a Delphi study to gain consensus on the definition of multimorbidity, the list and number of chronic conditions used for defining multimorbidity in the Singapore primary care setting. Our Delphi study comprised three rounds of online voting from purposively sampled family physicians in public and private settings. Delphi round 1 included open-ended questions for idea generation. The subsequent two rounds used questions with pre-selected options. Consensus was achieved based on a pre-defined criteria following an iterative process. The response rates for the three rounds were 61.7% (37/60), 86.5% (32/37) and 93.8% (30/32), respectively. Among 40 panellists who responded, 46.0% were 31-40 years old, 64.9% were male and 73.0% were from the public primary healthcare setting. Based on the findings of rounds 1, 2 and 3, consensus on the definition of a chronic condition, multimorbidity and finalised list of chronic conditions were achieved. For a condition to be chronic, it should last for six months or more, be recurrent or persistent, impact patients across multiple domains and require long-term management. The consensus-derived definition of multimorbidity is the presence of three or more chronic conditions from a finalised list of 23 chronic conditions. We anticipate that our findings will inform multimorbidity conceptualisation at the national level, standardise multimorbidity measurement in primary care and facilitate resource allocation for patients with multimorbidity.

Multimorbidity and depressive symptoms in older adults and the role of social support: Evidence using Canadian Longitudinal Study on Aging (CLSA) data

Background

The rising prevalence of multimorbidity poses challenges to health systems globally. The objectives of this study were to investigate: 1) the association between multimorbidity and depressive symptoms; and 2) whether social support plays a protective role in this association.

Methods

A prospective population-based cohort study was conducted to analyze baseline and 3-year follow-up data of 16,729 community dwelling participants aged 65 and above in the Canadian Longitudinal Study of Aging (CLSA). Multimorbidity was defined as having three or more chronic conditions. The 10-item Center for Epidemiologic Studies Depression scale (CESD-10) was used to measure depressive symptoms. The 19-item Medical Outcomes Study (MOS) Social Support Survey was employed to assess perceived social support. Multivariate logistic regression models were used to examine the association between multimorbidity, social support and depressive symptoms.

Results

Multimorbidity was very common among participants with a prevalence of 70.6%. Fifteen percent of participants had depressive symptoms at baseline. Multimorbidity was associated with increased odds of having depressive symptoms at 3-year follow-up (adjusted odds ratio, aOR = 1.51, 95% CI 1.33, 1.71), and developing depressive symptoms by follow-up among those with no depressive symptoms at baseline (aOR = 1.65, 95% CI 1.42, 1.92). Social support was consistently associated with decreased odds of depressive symptoms, regardless of level of multimorbidity.

Conclusion

Multimorbidity was positively associated with depressive symptoms over time, but social support served as a protective factor. As a modifiable, protective factor, emphasis should be placed in clinical practice to assess social support and refer patients to appropriate services, such as support groups. Similarly, health policy should focus on ensuring that older adults have access to social support opportunities as a way to promote mental health among older adults. Community organizations that offer social activities or support groups play a key role in this respect and should be adequately supported (e.g., with funding).

Use of home care services by older Veterans and dependants in Melbourne, Australia, 2007-2016

LAY SUMMARY

Military service has an impact on health and well-being across the life course. However, there is little research on older Veterans and dependants who use home care to enable them to remain living in the community. The authors analysed data from a Melbourne, Australia, home care organization’s electronic care records to explore the differences between clients supported by the Department of Veterans’ Affairs and clients in the general home nursing population. Results showed the greater needs of and complexity of care utilized by Veterans and dependants. Funding structures and support services need to account for these needs in older age.

Health status of recently arrived asylum seekers in their host country: results of a cross-sectional observational study

Background

The World Health Organization (WHO) considers that the heterogeneity of concepts and definitions of migrants is an obstacle to obtaining evidence to inform public health policies. There is no recent data on the health status of only asylum seekers who have recently arrived in their Western host country. The purpose of this study was to determine the health status of asylum seekers and search for explanatory factors for this health status.

Methods

This cross-sectional observational study screened the mental and somatic health of adult asylum seekers who had arrived in France within the past 21 days and went to the Marseille single center between March 1 and August 31, 2021. In order to study the explanatory factors of the asylum seekers' health status, a multivariate analysis was performed using a logistic regression model to predict the health status. Factors taken into account were those significantly associated with outcome (level < 0.05) in univariate analysis.

Results

In total, 419 asylum seekers were included and 96% CI95%[93;97.3] had at least one health disorder. Concerning mental health, 89% CI95% [85.1;91.4] had a mental disorder and in terms of somatic health exclusively, 66% CI95% [61.4;70.6] had at least one somatic disorder. Women were more likely to have a somatic disease OR = 1.80 [1.07; 3.05]. We found a statistically significant association between the presence of at least one disorder and sleeping in a public space OR = 3.4 [1.02;11.28] p = 0.046. This association is also found for mental disorders OR = 2.36 [1.16;4.84], p = 0.018.

Conclusions

Due to the high prevalence of health disorders our study found, asylum seekers are a population with many care needs when they arrive in their host country. The main factors linked to a poor health status seem to be related to a person’s sex, geographical origin and sleeping in a public space.