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Wheat CL, Wong ES, Gray KE, Stockdale SE, Nelson KM, Reddy A. Factors Associated With Use of the Preventive Health Inventory in US Veterans. JAMA Netw Open 2024; 7:e242717. [PMID: 38497962 PMCID: PMC10949100 DOI: 10.1001/jamanetworkopen.2024.2717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 01/24/2024] [Indexed: 03/19/2024] Open
Abstract
Importance The COVID-19 pandemic caused significant declines in the quality of preventive and chronic disease care. The Veterans Health Administration (VHA) used the Preventive Health Inventory (PHI), a multicomponent care management intervention, to catch up on care disrupted by the pandemic. Objective To identify key factors associated with PHI use. Design, Setting, and Participants This cohort study of veterans receiving primary care used administrative data from national VHA primary care clinics for February 1, 2021, through February 1, 2022. Exposure Patient PHI receipt. Main Outcomes and Measures The main outcomes were patient, practitioner, and clinic factors associated with PHI receipt. Binomial generalized linear models with fixed effects for clinic were used to analyze factors associated with receipt of PHI. Least absolute shrinkage and selection operator procedures were used for variable selection. Results A total of 4 358 038 veterans (mean [SD] age, 63.7 [16.0] years; 90% male; 76% non-Hispanic White) formed the study cohort, of whom 389 757 (9%) received the PHI. Veterans who received the PHI had higher mean Care Assessment Need (CAN) scores, which indicate the likelihood of hospitalization or death within 1 year (mean [SD], 51.9 [28.6] vs 47.2 [28.6]; standardized mean difference [SMD], -0.16). They were also more likely to live in urban areas (77% vs 64%; SMD, 0.28) and have a shorter drive distance to primary care (mean [SD], 13.2 [12.4] vs 15.7 [14.6] miles; SMD, 0.19). The mean outpatient use was higher among PHI recipients compared with non-PHI recipients (mean [SD], 18.4 [27.8] vs 15.1 [24.1] visits; SMD, -0.13). In addition, veterans with primary care practitioners with higher caseloads were more likely to receive the PHI (mean [SD], 778 [231] vs 744 [249] patients; SMD, -0.14), and they were more likely to be seen at larger clinics (mean [SD], 9670 [6876] vs 8786 [6892] patients; SMD, -0.13). Prior outpatient use and CAN score were associated with PHI receipt in the final model. Conclusions and Relevance In this cohort study of the VHA's PHI, patients with higher CAN scores and more outpatient use in the previous year were more likely to receive the PHI. This study identifies potential intervention points to improve care coordination for veterans.
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Affiliation(s)
- Chelle L. Wheat
- Center for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, Washington
| | - Edwin S. Wong
- Center for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, Washington
- Department of Health Systems and Population Health, University of Washington, Seattle
| | - Kristen E. Gray
- Center for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, Washington
- Department of Health Systems and Population Health, University of Washington, Seattle
| | - Susan E. Stockdale
- VA Greater Los Angeles Healthcare System, Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, California
- David Geffen School of Medicine, Department of Medicine, Division of General Internal Medicine, University of California at Los Angeles, Los Angeles
| | - Karin M. Nelson
- Center for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, Washington
- Department of Health Systems and Population Health, University of Washington, Seattle
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle
| | - Ashok Reddy
- Center for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, Washington
- Department of Health Systems and Population Health, University of Washington, Seattle
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle
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Ares-Blanco S, López-Rodríguez JA, Fontán Vela M, Polentinos-Castro E, del Cura-González I. Sex and income inequalities in preventive services in diabetes. Eur J Gen Pract 2023; 29:2159941. [PMID: 36661248 PMCID: PMC9870013 DOI: 10.1080/13814788.2022.2159941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 12/12/2022] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Cancer preventive services (gynaecological cancer screening, colon cancer screening) and cardiometabolic screening are recommended by guidelines to individuals. People with diabetes were less likely to receive them than those without diabetes in some studies. OBJECTIVES To analyse differences in the coverage of preventive services in people with diabetes compared to non-diabetic individuals and in people with diabetes according to sex and household income. METHODS We analysed data collected from the European Health Interview Survey 2013-2015, including individuals aged 40-74 (n = 179,318), 15,172 with diabetes from 29 countries. The income of a household (HHI) was described in quintiles. The relationship between the coverage of preventive services (cardiometabolic, vaccination, cancer screening) and sociodemographic characteristics was analysed with multiple logistic regression. RESULTS Women comprised 53.8% of the total and 40% were 60-74 years. People with diabetes compared to those without diabetes had higher reported coverage of cardiometabolic screening (98.4% vs. 90.0% in cholesterol measurement; 97.0% vs. 93.6% in blood pressure measurement), colorectal cancer screening (27.1% vs. 24.6%) but lower coverage of gynaecological cancer screening (mammography: 29.2% vs. 33.5%, pap smear test: 28.3% vs. 37.9%). Among diabetic patients, women were less likely to receive cholesterol screening (OR = 0.81; 95% CI: 0.72-0.91) and colon cancer screening (OR = 0.79; 95% CI: 0.73-0.86) compared to men. Being affluent was positively associated with receiving cardiometabolic screening and mammography in diabetic patients. CONCLUSION People with diabetes reported higher coverage of preventive services except gynaecological cancer screening. Disparities were found in diabetes among women and less affluent individuals.
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Affiliation(s)
- Sara Ares-Blanco
- Federica Montseny Health Centre, Gerencia Asistencial Atención Primaria, Servicio Madrileño de Salud, Madrid, Spain
- Medical Specialties and Public Health, School of Health Sciences, University Rey Juan Carlos, Alcorcón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Juan A. López-Rodríguez
- Medical Specialties and Public Health, School of Health Sciences, University Rey Juan Carlos, Alcorcón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- General Ricardos Health Centre, Gerencia Asistencial Atención Primaria, Servicio Madrileño de Salud, Madrid, Spain
- Primary Care Research Unit, Gerencia de Atención Primaria, Servicio Madrileño de Salud, Madrid, Spain
- Health Services Research on Chronic Patients Network (REDISSEC), Health Outcomes-Oriented Cooperative Research Networks (RICORS-RICAPS), ISCIII, Madrid, Spain
| | - Mario Fontán Vela
- Medicina Preventiva Department, Hospital Universitario Infanta Leonor, Madrid, Spain
- Public Health and Epidemiology Research Group, School of Medicine, Universidad de Alcalá, Madrid, Spain
| | - Elena Polentinos-Castro
- Medical Specialties and Public Health, School of Health Sciences, University Rey Juan Carlos, Alcorcón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Primary Care Research Unit, Gerencia de Atención Primaria, Servicio Madrileño de Salud, Madrid, Spain
- Health Services Research on Chronic Patients Network (REDISSEC), Health Outcomes-Oriented Cooperative Research Networks (RICORS-RICAPS), ISCIII, Madrid, Spain
| | - Isabel del Cura-González
- Medical Specialties and Public Health, School of Health Sciences, University Rey Juan Carlos, Alcorcón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Primary Care Research Unit, Gerencia de Atención Primaria, Servicio Madrileño de Salud, Madrid, Spain
- Health Services Research on Chronic Patients Network (REDISSEC), Health Outcomes-Oriented Cooperative Research Networks (RICORS-RICAPS), ISCIII, Madrid, Spain
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3
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Grundy EM, Stuchbury R. Multimorbidity as assessed by reporting of multiple causes of death: variations by period, sociodemographic characteristics and place of death among older decedents in England and Wales, 2001-2017. J Epidemiol Community Health 2022; 76:jech-2021-217846. [PMID: 35654580 PMCID: PMC9279827 DOI: 10.1136/jech-2021-217846] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 05/06/2022] [Indexed: 12/04/2022]
Abstract
BACKGROUND Multimorbidity is common at older ages and is associated with disability, frailty and poor quality of life. Research using clinical databases and surveys has shown associations between multimorbidity and indicators of social disadvantage. Use of multiple coded death registration data has been proposed as an additional source which may also provide insights into quality of death certification. METHODS We investigate trends in reporting multiple causes of death during 2001-2017 among decedents aged 65 years and over included in a census-based sample of 1% of the England and Wales population (Office for National Statistics Longitudinal Study). Using Poisson regression analysis, we analyse variations in number of mentions of causes of death recorded by time period, place of death, age, sex and marital status at death and indicators of health status and individual and area socioeconomic disadvantage reported at the census prior to death. RESULTS Number of mentions of causes recorded at death registration increased 2001-2017, increased with age, peaking among decedents aged 85-9 years, and was positively associated with indicators of prior disadvantage and poor health, although effects were small. Number of mentions was highest for hospital decedents and similar for those dying in care homes or their own homes. CONCLUSION Socioeconomic disadvantage, prior poor health, dying in hospital and older age-although not extreme old age-are associated with dying with more recorded conditions. Results may reflect both differences in multimorbidity at death and variations in quality of medical certification of death. Quality of death certification for decedents in care homes needs further investigation.
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4
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Dautzenberg L, Beglinger S, Tsokani S, Zevgiti S, Raijmann RCMA, Rodondi N, Scholten RJPM, Rutjes AWS, Di Nisio M, Emmelot-Vonk M, Tricco AC, Straus SE, Thomas S, Bretagne L, Knol W, Mavridis D, Koek HL. Interventions for preventing falls and fall-related fractures in community-dwelling older adults: A systematic review and network meta-analysis. J Am Geriatr Soc 2021; 69:2973-2984. [PMID: 34318929 PMCID: PMC8518387 DOI: 10.1111/jgs.17375] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 05/19/2021] [Accepted: 06/11/2021] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To compare the effectiveness of single, multiple, and multifactorial interventions to prevent falls and fall-related fractures in community-dwelling older persons. METHODS MEDLINE, Embase, and Cochrane Central Register of Controlled Trials were systematically searched for randomized controlled trials (RCTs) evaluating the effectiveness of fall prevention interventions in community-dwelling adults aged ≥65 years, from inception until February 27, 2019. Two large RCTs (published in 2020 after the search closed) were included in post hoc analyses. Pairwise meta-analysis and network meta-analysis (NMA) were conducted. RESULTS NMA including 192 studies revealed that the following single interventions, compared with usual care, were associated with reductions in number of fallers: exercise (risk ratio [RR] 0.83; 95% confidence interval [CI] 0.77-0.89) and quality improvement strategies (e.g., patient education) (RR 0.90; 95% CI 0.83-0.98). Exercise as a single intervention was associated with a reduction in falls rate (RR 0.79; 95% CI 0.73-0.86). Common components of multiple interventions significantly associated with a reduction in number of fallers and falls rate were exercise, assistive technology, environmental assessment and modifications, quality improvement strategies, and basic falls risk assessment (e.g., medication review). Multifactorial interventions were associated with a reduction in falls rate (RR 0.87; 95% CI 0.80-0.95), but not with a reduction in number of fallers (RR 0.95; 95% CI 0.89-1.01). The following single interventions, compared with usual care, were associated with reductions in number of fall-related fractures: basic falls risk assessment (RR 0.60; 95% CI 0.39-0.94) and exercise (RR 0.62; 95% CI 0.42-0.90). CONCLUSIONS In keeping with Tricco et al. (2017), several single and multiple fall prevention interventions are associated with fewer falls. In addition to Tricco, we observe a benefit at the NMA-level of some single interventions on preventing fall-related fractures.
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Affiliation(s)
- Lauren Dautzenberg
- Department of Geriatric Medicine, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Shanthi Beglinger
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Sofia Tsokani
- Department of Primary Education, School of Education, University of Ioannina, Ioannina, Greece
| | - Stella Zevgiti
- Department of Primary Education, School of Education, University of Ioannina, Ioannina, Greece
| | - Renee C M A Raijmann
- Department of Geriatric Medicine, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Nicolas Rodondi
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Rob J P M Scholten
- Cochrane Netherlands/Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Anne W S Rutjes
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland.,Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| | - Marcello Di Nisio
- Department of Medicine and Ageing Sciences, University G. D'Annunzio, Chieti, Italy
| | - Marielle Emmelot-Vonk
- Department of Geriatric Medicine, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Andrea C Tricco
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada.,Epidemiology Division and Institute for Health Policy, Management, and Evaluation, Dalla Lana School of Public Health and Institute for Health, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Sharon E Straus
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada.,Epidemiology Division and Institute for Health Policy, Management, and Evaluation, Dalla Lana School of Public Health and Institute for Health, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Department of Geriatric Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sonia Thomas
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Lisa Bretagne
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Wilma Knol
- Department of Geriatric Medicine, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Dimitris Mavridis
- Department of Primary Education, School of Education, University of Ioannina, Ioannina, Greece.,Paris Descartes University, Sorbonne Paris Cité, Faculté de Médecine, Paris, France
| | - Huiberdina L Koek
- Department of Geriatric Medicine, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
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5
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Lee ES, Koh HL, Ho EQY, Teo SH, Wong FY, Ryan BL, Fortin M, Stewart M. Systematic review on the instruments used for measuring the association of the level of multimorbidity and clinically important outcomes. BMJ Open 2021; 11:e041219. [PMID: 33952533 PMCID: PMC8103380 DOI: 10.1136/bmjopen-2020-041219] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES There are multiple instruments for measuring multimorbidity. The main objective of this systematic review was to provide a list of instruments that are suitable for use in studies aiming to measure the association of a specific outcome with different levels of multimorbidity as the main independent variable in community-dwelling individuals. The secondary objective was to provide details of the requirements, strengths and limitations of these instruments, and the chosen outcomes. METHODS We conducted the review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PROSPERO registration number: CRD42018105297). We searched MEDLINE, Embase and CINAHL electronic databases published in English and manually searched the Journal of Comorbidity between 1 January 2010 and 23 October 2020 inclusive. Studies also had to select adult patients from primary care or general population and had at least one specified outcome variable. Two authors screened the titles, abstracts and full texts independently. Disagreements were resolved with a third author. The modified Newcastle-Ottawa Scale was used for quality assessment. RESULTS Ninety-six studies were identified, with 69 of them rated to have a low risk of bias. In total, 33 unique instruments were described. Disease Count and weighted indices like Charlson Comorbidity Index were commonly used. Other approaches included pharmaceutical-based instruments. Disease Count was the common instrument used for measuring all three essential core outcomes of multimorbidity research: mortality, mental health and quality of life. There was a rise in the development of novel weighted indices by using prognostic models. The data obtained for measuring multimorbidity were from sources including medical records, patient self-reports and large administrative databases. CONCLUSIONS We listed the details of 33 instruments for measuring the level of multimorbidity as a resource for investigators interested in the measurement of multimorbidity for its association with or prediction of a specific outcome.
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Affiliation(s)
- Eng Sing Lee
- Clinical Research Unit, National Healthcare Group Polyclinics, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Hui Li Koh
- Clinical Research Unit, National Healthcare Group Polyclinics, Singapore
| | - Elaine Qiao-Ying Ho
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Sok Huang Teo
- Clinical Research Unit, National Healthcare Group Polyclinics, Singapore
| | - Fang Yan Wong
- Clinical Research Unit, National Healthcare Group Polyclinics, Singapore
| | - Bridget L Ryan
- Department of Epidemiology and Biostatistics, Western University Schulich School of Medicine and Dentistry, London, Ontario, Canada
- Centre for Studies in Family Medicine, Department of Family Medicine, Western University Schulich School of Medicine and Dentistry, London, Ontario, Canada
| | - Martin Fortin
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Moira Stewart
- Centre for Studies in Family Medicine, Department of Family Medicine, Western University Schulich School of Medicine and Dentistry, London, Ontario, Canada
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Ukhanova MA, Tillotson CJ, Marino M, Huguet N, Quiñones AR, Hatch BA, Schmidt T, DeVoe JE. Uptake of Preventive Services Among Patients With and Without Multimorbidity. Am J Prev Med 2020; 59:621-629. [PMID: 32978012 PMCID: PMC7577968 DOI: 10.1016/j.amepre.2020.04.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Revised: 04/12/2020] [Accepted: 04/27/2020] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Patients with multiple chronic conditions (multimorbidity) are seen commonly in primary care practices and often have suboptimal uptake of preventive care owing to competing treatment demands. The complexity of multimorbidity patterns and their impact on receiving preventive services is not fully understood. This study identifies multimorbidity combinations associated with low receipt of preventive services. METHODS This was a retrospective cohort study of U.S. community health center patients aged ≥19 years. Electronic health record data from 209 community health centers for the January 1, 2014-December 31, 2017 study period were analyzed in 2018-2019. Multimorbidity patterns included physical only, mental health only, and physical and mental health multimorbidity patterns, with no multimorbidity as a reference category. Electronic health record-based preventive ratios (number of months services were up-to-date/total months the patient was eligible for services) were calculated for the 14 preventive services. Negative binomial regression models assessed the relationship between multimorbidity physical and/or mental health patterns and the preventive ratio for each service. RESULTS There was a variation in receipt of preventive care between multimorbidity groups: individuals with mental health only multimorbidity were less likely to be up-to-date with cardiometabolic and cancer screenings than the no multimorbidity group or groups with physical health conditions, and the physical only multimorbidity group had low rates of depression screening. CONCLUSIONS This study provided critical insights into receipt of preventive service among adults with multimorbidity using a more precise method for measuring up-to-date preventive care delivery. Findings would be useful to identify target populations for future intervention programs to improve preventive care.
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Affiliation(s)
- Maria A Ukhanova
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon.
| | | | - Miguel Marino
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon; Division of Biostatistics, School of Public Health, Oregon Health & Science University - Portland State University, Portland, Oregon
| | - Nathalie Huguet
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon
| | - Ana R Quiñones
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon
| | - Brigit A Hatch
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon; Research Department, OCHIN Inc., Portland, Oregon
| | | | - Jennifer E DeVoe
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon
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7
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Rozsnyai Z, Jungo KT, Reeve E, Poortvliet RKE, Rodondi N, Gussekloo J, Streit S. What do older adults with multimorbidity and polypharmacy think about deprescribing? The LESS study - a primary care-based survey. BMC Geriatr 2020; 20:435. [PMID: 33129274 PMCID: PMC7602330 DOI: 10.1186/s12877-020-01843-x] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 10/21/2020] [Indexed: 12/29/2022] Open
Abstract
Background Multimorbidity and polypharmacy are very common in older adults in primary care. Ideally, general practitioners (GPs), should regularly review medication lists to identify inappropriate medication(s) and, where appropriate, deprescribe. However, it remains challenging to deprescribe given time constraints and few recommendations from guidelines. Further, patient related barriers and enablers to deprescribing have to be accounted for. The aim of this study was to identify barriers and enablers to deprescribing as reported by older adults with polypharmacy and multimorbidity. Methods We conducted a survey among participants aged ≥70 years, with multimorbidity (≥3 chronic conditions) and polypharmacy (≥5 chronic medications). We invited Swiss GPs, to recruit eligible patients who then completed a paper-based survey on demographics, medications and chronic conditions. We used the revised Patients’ Attitudes Towards Deprescribing (rPATD) questionnaire and added twelve additional Likert scale questions and two open-ended questions to assess barriers and enablers towards deprescribing, which we coded and categorized into meaningful themes. Result Sixty four Swiss GPs consented to recruit 5–6 patients each and returned 300 participant responses. Participants were 79.1 years (SD 5.7), 47% female, 34% lived alone, and 86% managed their medications themselves. Sixty-seven percent of participants took 5–9 regular medicines and 24% took ≥10 medicines. The majority of participants (77%) were willing to deprescribe one or more of their medicines if their doctor said it was possible. There was no association with sex, age or the number of medicines and willingness to deprescribe. After adjustment for baseline characteristics, there was a strong positive association between willingness to deprescribe and saying that because they have a good relationship with their GP, they would feel that deprescribing was safe OR 11.3 (95% CI: 4.64–27.3) and agreeing that they would be willing to deprescribe if new studies showed an avoidable risk OR 8.0 (95% CI 3.79–16.9). From the open questions, the most mentioned barriers towards deprescribing were patients feeling well on their current medicines and being convinced that they need all their medicines. Conclusions Most older adults with polypharmacy are willing to deprescribe. GPs may be able to increase deprescribing by building trust with their patients and communicating evidence about the risks of medication use. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-020-01843-x.
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Affiliation(s)
- Zsofia Rozsnyai
- Institute of Primary Health Care Bern (BIHAM), University of Bern, Mittelstrasse 43, 3012, Bern, Switzerland
| | - Katharina Tabea Jungo
- Institute of Primary Health Care Bern (BIHAM), University of Bern, Mittelstrasse 43, 3012, Bern, Switzerland.,Graduate School for Health Sciences, University of Bern, Bern, Switzerland
| | - Emily Reeve
- Quality Use of Medicines and Pharmacy Research Centre, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide, SA, Australia.,NHMRC Cognitive Decline Partnership Centre, Kolling Institute of Medical Research, Northern Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia.,Geriatric Medicine Research and College of Pharmacy, Dalhousie University and Nova Scotia Health Authority, Halifax, NS, Canada
| | - Rosalinde K E Poortvliet
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Nicolas Rodondi
- Institute of Primary Health Care Bern (BIHAM), University of Bern, Mittelstrasse 43, 3012, Bern, Switzerland.,Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jacobijn Gussekloo
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands.,Department of Internal Medicine, Section Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Sven Streit
- Institute of Primary Health Care Bern (BIHAM), University of Bern, Mittelstrasse 43, 3012, Bern, Switzerland.
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8
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Yamashita H, Takahashi Y, Ishizaki T, Imura H, Nakayama T. Associations of multimorbidity with breast, cervical, and colorectal cancer screening delivery: a cross-sectional study of a nationally representative Japanese sample. Cancer Epidemiol 2020; 69:101798. [PMID: 32980753 DOI: 10.1016/j.canep.2020.101798] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 07/31/2020] [Accepted: 08/10/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Multimorbidity is associated with a high mortality rate and low health-related quality of life. Previous studies have indicated that multimorbidity tends to be associated with not receiving cancer screening, although this association remains unclear. This study aimed to investigate the associations between multimorbidity and the delivery of breast, cervical, and colorectal cancer screening in Japan, and to identify subgroups that did not receive cancer screening. METHODS This study used cross-sectional data from the 2016 Comprehensive Survey of Living Conditions, which used a stratified random sample of the general Japanese population. Multivariable logistic regression models were used to evaluate the associations between the number of chronic conditions and each cancer's screening proportion. The relevant covariates included age, marital status, education level, occupation, and household income. RESULTS Relative to subjects with no chronic conditions, subjects with two chronic conditions received more screening for breast, cervical, and colorectal cancers (breast cancer, adjusted odds ratio [aOR]: 5.42, 95% confidence interval [CI]: 2.80-10.5; cervical cancer, aOR: 4.59, 95% CI: 2.03-10.4; male colorectal cancer, aOR: 3.26, 95% CI: 1.29-8.24; female colorectal cancer, aOR: 1.05, 95% CI: 0.39-2.81). Low socioeconomic status was associated with not receiving any type of cancer screening consistently. CONCLUSION Multimorbidity and high socioeconomic status were associated with higher proportions of screening for breast, cervical, and colorectal cancers in the Japanese population. More aggressive strategies may be needed to promote screening among Japanese individuals with no chronic conditions and individuals with low socioeconomic status.
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Affiliation(s)
- Hiromitsu Yamashita
- Department of Health Informatics, Kyoto University School of Public Health, Yoshida Konoe-cho, Sakyo-ku, Kyoto, Kyoto 606-8501, Japan.
| | - Yoshimitsu Takahashi
- Department of Health Informatics, Kyoto University School of Public Health, Yoshida Konoe-cho, Sakyo-ku, Kyoto, Kyoto 606-8501, Japan.
| | - Tatsuro Ishizaki
- Human Care Research Team, Tokyo Metropolitan Institute of Gerontology, 35-2 Sakae-cho, Itabashi-ku, Tokyo 173-0015, Japan.
| | - Haruki Imura
- Department of Health Informatics, Kyoto University School of Public Health, Yoshida Konoe-cho, Sakyo-ku, Kyoto, Kyoto 606-8501, Japan.
| | - Takeo Nakayama
- Department of Health Informatics, Kyoto University School of Public Health, Yoshida Konoe-cho, Sakyo-ku, Kyoto, Kyoto 606-8501, Japan.
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9
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Cohen-Stavi CJ, Key C, Giveon S, Molcho T, Balicer RD, Shadmi E. Assessing guideline-concordant care for patients with multimorbidity treated in a care management setting. Fam Pract 2020; 37:479-485. [PMID: 32219299 DOI: 10.1093/fampra/cmaa024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Disease-specific guidelines are not aligned with multimorbidity care complexity. Meeting all guideline-recommended care for multimorbid patients has been estimated but not demonstrated across multiple guidelines. OBJECTIVE Measure guideline-concordant care for patients with multimorbidity; assess in what types of care and by whom (clinician or patient) deviation from guidelines occurs and evaluate whether patient characteristics are associated with concordance. METHODS A retrospective cohort study of care received over 1 year, conducted across 11 primary care clinics within the context of multimorbidity-focused care management program. Patients were aged 45+ years with more than two common chronic conditions and were sampled based on either being new (≤6 months) or veteran to the program (≥1 year). MEASURES Three guideline concordance measures were calculated for each patient out of 44 potential guideline-recommended care processes for nine chronic conditions: overall score; referral score (proportion of guideline-recommended care referred) and patient-only score (proportion of referred care completed by patients). Guideline concordance was stratified by care type. RESULTS 4386 care processes evaluated among 204 patients, mean age = 72.3 years (standard deviation = 9.7). Overall, 79.2% of care was guideline concordant, 87.6% was referred according to guidelines and patients followed 91.4% of referred care. Guideline-concordant care varied across care types. Age, morbidity burden and whether patients were new or veteran to the program were associated with guideline concordance. CONCLUSIONS Patients with multimorbidity do not receive ~20% of guideline recommendations, mostly due to clinicians not referring care. Determining the types of care for which the greatest deviation from guidelines exists can inform the tailoring of care for multimorbidity patients.
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Affiliation(s)
- Chandra J Cohen-Stavi
- Clalit Research Institute, Clalit Health Services, Tel Aviv.,Cheryl Spencer Department of Nursing, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa
| | | | - Shmuel Giveon
- Community Medical Division, Clalit Health Services, Tel Aviv
| | | | - Ran D Balicer
- Clalit Research Institute, Clalit Health Services, Tel Aviv.,Epidemiology Department, Ben Gurion University of the Negev, Be'er Sheba, Israel
| | - Efrat Shadmi
- Clalit Research Institute, Clalit Health Services, Tel Aviv.,Cheryl Spencer Department of Nursing, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa
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10
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Geneviève LD, Martani A, Mallet MC, Wangmo T, Elger BS. Factors influencing harmonized health data collection, sharing and linkage in Denmark and Switzerland: A systematic review. PLoS One 2019; 14:e0226015. [PMID: 31830124 PMCID: PMC6907832 DOI: 10.1371/journal.pone.0226015] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 11/18/2019] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION The digitalization of medicine has led to a considerable growth of heterogeneous health datasets, which could improve healthcare research if integrated into the clinical life cycle. This process requires, amongst other things, the harmonization of these datasets, which is a prerequisite to improve their quality, re-usability and interoperability. However, there is a wide range of factors that either hinder or favor the harmonized collection, sharing and linkage of health data. OBJECTIVE This systematic review aims to identify barriers and facilitators to health data harmonization-including data sharing and linkage-by a comparative analysis of studies from Denmark and Switzerland. METHODS Publications from PubMed, Web of Science, EMBASE and CINAHL involving cross-institutional or cross-border collection, sharing or linkage of health data from Denmark or Switzerland were searched to identify the reported barriers and facilitators to data harmonization. RESULTS Of the 345 projects included, 240 were single-country and 105 were multinational studies. Regarding national projects, a Swiss study reported on average more barriers and facilitators than a Danish study. Barriers and facilitators of a technical nature were most frequently reported. CONCLUSION This systematic review gathered evidence from Denmark and Switzerland on barriers and facilitators concerning data harmonization, sharing and linkage. Barriers and facilitators were strictly interrelated with the national context where projects were carried out. Structural changes, such as legislation implemented at the national level, were mirrored in the projects. This underlines the impact of national strategies in the field of health data. Our findings also suggest that more openness and clarity in the reporting of both barriers and facilitators to data harmonization constitute a key element to promote the successful management of new projects using health data and the implementation of proper policies in this field. Our study findings are thus meaningful beyond these two countries.
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Affiliation(s)
| | - Andrea Martani
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland
| | | | - Tenzin Wangmo
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland
| | - Bernice Simone Elger
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland
- University Center of Legal Medicine, University of Geneva, Geneva, Switzerland
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11
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Allenbach VP, Rozsnyai Z, Streit S. [Promising Future in General Internal Medicine for the Next Generation of Physicians]. PRAXIS 2018; 107:699-704. [PMID: 29921179 DOI: 10.1024/1661-8157/a003001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Promising Future in General Internal Medicine for the Next Generation of Physicians Abstract. We are facing a lack of specialists in general internal medicine in general practitioners' practices as well as in hospitals, while at the same time the population ages and usually displays several chronic diseases (multimorbidity). Thanks to more university places, an improved job description for general internal medicine and new further education offers (curricula), interest in general internal medicine increased again, as surveys of students indicate. The young generation of family doctors and generalists in hospitals wishes flexible working conditions in order to reconcile work, family and spare time in the best possible way. Working atmosphere and colleagues have a high priority. These wishes must now be incorporated into attractive further training with flexible curricula and mentoring offers so that young talents can successfully be promoted.
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Affiliation(s)
| | - Zsofia Rozsnyai
- 1 Berner Institut für Hausarztmedizin (BIHAM), Universität Bern
| | - Sven Streit
- 1 Berner Institut für Hausarztmedizin (BIHAM), Universität Bern
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12
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Schiøtz ML, Høst D, Christensen MB, Domínguez H, Hamid Y, Almind M, Sørensen KL, Saxild T, Holm RH, Frølich A. Quality of care for people with multimorbidity - a case series. BMC Health Serv Res 2017; 17:745. [PMID: 29151022 PMCID: PMC5694163 DOI: 10.1186/s12913-017-2724-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 11/13/2017] [Indexed: 12/16/2022] Open
Abstract
Background Multimorbidity is becoming increasingly prevalent and presents challenges for healthcare providers and systems. Studies examining the relationship between multimorbidity and quality of care report mixed findings. The purpose of this study was to investigate quality of care for people with multimorbidity in the publicly funded healthcare system in Denmark. Methods To investigate the quality of care for people with multimorbidity different groups of clinicians from the hospital, general practice and the municipality reviewed records from 23 persons with multimorbidity and discussed them in three focus groups. Before each focus group, clinicians were asked to review patients’ medical records and assess their care by responding to a questionnaire. Medical records from 2013 from hospitals, general practice, and health centers in the local municipality were collected and linked for the 23 patients. Further, two clinical pharmacologists reviewed the appropriateness of medications listed in patient records. Results The review of the patients’ records conducted by three groups of clinicians revealed that around half of the patients received adequate care for the single condition which prompted the episode of care such as a hospitalization, a visit to an outpatient clinic or the general practitioner. Further, the care provided to approximately two-thirds of the patients did not take comorbidities into account and insufficiently addressed more diffuse symptoms or problems. The review of the medication lists revealed that the majority of the medication lists contained inappropriate medications and that there were incongruity in medication listed in the primary and secondary care sector. Several barriers for providing high quality care were identified. These included relative short consultation times in general practice and outpatient clinics, lack of care coordinators, and lack of shared IT-system proving an overview of the treatment. Conclusions Our findings reveal quality of care deficiencies for people with multimorbidity. Suggestions for care improvement for people with multimorbidity includes formally assigned responsibility for care coordination, a change in the financial incentive structure towards a system rewarding high quality care and care focusing on prevention of disease exacerbation, as well as implementing shared medical record systems.
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Affiliation(s)
- Michaela L Schiøtz
- Cross-sectoral Research Unit, The Danish Capital Region, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark. .,Research Unit for Chronic Conditions, Bispebjerg and Frederiksberg Hospitals, University of Copenhagen, Copenhagen, Denmark.
| | - Dorte Høst
- Cross-sectoral Research Unit, The Danish Capital Region, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark.,Research Unit for Chronic Conditions, Bispebjerg and Frederiksberg Hospitals, University of Copenhagen, Copenhagen, Denmark
| | - Mikkel B Christensen
- Department of Clinical Pharmacology, Bispebjerg and Frederiksberg Hospitals, University of Copenhagen, Copenhagen, Denmark
| | - Helena Domínguez
- Department of Cardiology, Bispebjerg and Frederiksberg Hospitals, University of Copenhagen, Copenhagen, Denmark
| | - Yasmin Hamid
- Department of Endocrinology, Bispebjerg and Frederiksberg Hospitals, University of Copenhagen, Copenhagen, Denmark
| | - Merete Almind
- Department of Respiratory Medicine, Bispebjerg and Frederiksberg Hospitals, University of Copenhagen, Copenhagen, Denmark
| | | | | | - Rikke Høgsbro Holm
- Health Prevention Center, Municipality of Copenhagen, Copenhagen, Denmark
| | - Anne Frølich
- Research Unit for Chronic Conditions, Department of Clinical Epidemiology, Bispebjerg and Frederiksberg Hospitals, University of Copenhagen, Copenhagen, Denmark
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13
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Müller M, Ricklin ME, Weiler S, Exadaktylos AK, Arampatzis S. Emergency medicine in the extreme geriatric era: A retrospective analysis of patients aged in their mid 90s and older in the emergency department. Geriatr Gerontol Int 2017; 18:415-420. [DOI: 10.1111/ggi.13192] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 06/21/2017] [Accepted: 08/27/2017] [Indexed: 12/01/2022]
Affiliation(s)
- Martin Müller
- Department of Emergency Medicine, Inselspital, Bern University Hospital; University of Bern; Bern Switzerland
| | - Meret E Ricklin
- Department of Emergency Medicine, Inselspital, Bern University Hospital; University of Bern; Bern Switzerland
| | - Stefan Weiler
- Department of Nephrology, Hypertension and Clinical Pharmacology, Inselspital, Bern University Hospital; University of Bern; Bern Switzerland
- Department of Clinical Pharmacology and Toxicology, University Hospital Zurich; University of Zurich; Zurich Switzerland
| | - Aristomenis K Exadaktylos
- Department of Emergency Medicine, Inselspital, Bern University Hospital; University of Bern; Bern Switzerland
| | - Spyridon Arampatzis
- Department of Nephrology, Hypertension and Clinical Pharmacology, Inselspital, Bern University Hospital; University of Bern; Bern Switzerland
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14
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Chen LM, Epstein AM, Orav EJ, Filice CE, Samson LW, Joynt Maddox KE. Association of Practice-Level Social and Medical Risk With Performance in the Medicare Physician Value-Based Payment Modifier Program. JAMA 2017; 318:453-461. [PMID: 28763549 PMCID: PMC5817610 DOI: 10.1001/jama.2017.9643] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
IMPORTANCE Medicare recently launched the Physician Value-Based Payment Modifier (PVBM) Program, a mandatory pay-for-performance program for physician practices. Little is known about performance by practices that serve socially or medically high-risk patients. OBJECTIVE To compare performance in the PVBM Program by practice characteristics. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional observational study using PVBM Program data for payments made in 2015 based on performance of large US physician practices caring for fee-for-service Medicare beneficiaries in 2013. EXPOSURES High social risk (defined as practices in the top quartile of proportion of patients dually eligible for Medicare and Medicaid) and high medical risk (defined as practices in the top quartile of mean Hierarchical Condition Category risk score among fee-for-service beneficiaries). MAIN OUTCOMES AND MEASURES Quality and cost z scores based on a composite of individual measures. Higher z scores reflect better performance on quality; lower scores, better performance on costs. RESULTS Among 899 physician practices with 5 189 880 beneficiaries, 547 practices were categorized as low risk (neither high social nor high medical risk) (mean, 7909 beneficiaries; mean, 320 clinicians), 128 were high medical risk only (mean, 3675 beneficiaries; mean, 370 clinicians), 102 were high social risk only (mean, 1635 beneficiaries; mean, 284 clinicians), and 122 were high medical and social risk (mean, 1858 beneficiaries; mean, 269 clinicians). Practices categorized as low risk performed the best on the composite quality score (z score, 0.18 [95% CI, 0.09 to 0.28]) compared with each of the practices categorized as high risk (high medical risk only: z score, -0.55 [95% CI, -0.77 to -0.32]; high social risk only: z score, -0.86 [95% CI, -1.17 to -0.54]; and high medical and social risk: -0.78 [95% CI, -1.04 to -0.51]) (P < .001 across groups). Practices categorized as high social risk only performed the best on the composite cost score (z score, -0.52 [95% CI, -0.71 to -0.33]), low risk had the next best cost score (z score, -0.18 [95% CI, -0.25 to -0.10]), then high medical and social risk (z score, 0.40 [95% CI, 0.23 to 0.57]), and then high medical risk only (z score, 0.82 [95% CI, 0.65 to 0.99]) (P < .001 across groups). Total per capita costs were $9506 for practices categorized as low risk, $13 683 for high medical risk only, $8214 for high social risk only, and $11 692 for high medical and social risk. These patterns were associated with fewer bonuses and more penalties for high-risk practices. CONCLUSIONS AND RELEVANCE During the first year of the Medicare Physician Value-Based Payment Modifier Program, physician practices that served more socially high-risk patients had lower quality and lower costs, and practices that served more medically high-risk patients had lower quality and higher costs.
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Affiliation(s)
- Lena M. Chen
- Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
- Office of the Assistant Secretary for Planning and Evaluation, US Department of Health and Human Services, Washington, DC
| | - Arnold M. Epstein
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - E. John Orav
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Clara E. Filice
- Atrius Health, Newton, Massachusetts
- Now with Commonwealth Medicine, University of Massachusetts Medical School, Shrewsbury
| | - Lok Wong Samson
- Office of the Assistant Secretary for Planning and Evaluation, US Department of Health and Human Services, Washington, DC
| | - Karen E. Joynt Maddox
- Office of the Assistant Secretary for Planning and Evaluation, US Department of Health and Human Services, Washington, DC
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
- Now with Washington University School of Medicine, St Louis, Missouri
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15
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Déruaz-Luyet A, N'Goran AA, Senn N, Bodenmann P, Pasquier J, Widmer D, Tandjung R, Rosemann T, Frey P, Streit S, Zeller A, Haller DM, Excoffier S, Burnand B, Herzig L. Multimorbidity and patterns of chronic conditions in a primary care population in Switzerland: a cross-sectional study. BMJ Open 2017; 7:e013664. [PMID: 28674127 PMCID: PMC5734197 DOI: 10.1136/bmjopen-2016-013664] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To characterise in details a random sample of multimorbid patients in Switzerland and to evaluate the clustering of chronic conditions in that sample. METHODS 100 general practitioners (GPs) each enrolled 10 randomly selected multimorbid patients aged ≥18 years old and suffering from at least three chronic conditions. The prevalence of 75 separate chronic conditions from the International Classification of Primary Care-2 (ICPC-2) was evaluated in these patients. Clusters of chronic conditions were studied in parallel. RESULTS The final database included 888 patients. Mean (SD) patient age was 73.0 (12.0) years old. They suffered from 5.5 (2.2) chronic conditions and were prescribed 7.7 (3.5) drugs; 25.7% suffered from depression. Psychological conditions were more prevalent among younger individuals (≤66 years old). Cluster analysis of chronic conditions with a prevalence ≥5% in the sample revealed four main groups of conditions: (1) cardiovascular risk factors and conditions, (2) general age-related and metabolic conditions, (3) tobacco and alcohol dependencies, and (4) pain, musculoskeletal and psychological conditions. CONCLUSION Given the emerging epidemic of multimorbidity in industrialised countries, accurately depicting the multiple expressions of multimorbidity in family practices' patients is a high priority. Indeed, even in a setting where patients have direct access to medical specialists, GPs nevertheless retain a key role as coordinators and often as the sole medical reference for multimorbid patients.
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Affiliation(s)
- Anouk Déruaz-Luyet
- Institute of Family Medicine, University of Lausanne, Lausanne, Switzerland
| | | | - Nicolas Senn
- Institute of Family Medicine, University of Lausanne, Lausanne, Switzerland
| | - Patrick Bodenmann
- Department of Ambulatory Care and Community Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Jérôme Pasquier
- Institute of Social and Preventive Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Daniel Widmer
- Institute of Family Medicine, University of Lausanne, Lausanne, Switzerland
| | - Ryan Tandjung
- Institute of Primary Care, University of Zurich, Zurich, Switzerland
| | - Thomas Rosemann
- Institute of Primary Care, University of Zurich, Zurich, Switzerland
| | - Peter Frey
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Sven Streit
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Andreas Zeller
- Centre for Primary Health Care, University of Basel, Basel, Switzerland
| | - Dagmar M Haller
- Primary Care Unit, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Sophie Excoffier
- Primary Care Unit, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Bernard Burnand
- Institute of Social and Preventive Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Lilli Herzig
- Institute of Family Medicine, University of Lausanne, Lausanne, Switzerland
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16
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Aubert CE, Streit S, Da Costa BR, Collet TH, Cornuz J, Gaspoz JM, Bauer D, Aujesky D, Rodondi N. Polypharmacy and specific comorbidities in university primary care settings. Eur J Intern Med 2016; 35:35-42. [PMID: 27289492 DOI: 10.1016/j.ejim.2016.05.022] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 05/19/2016] [Accepted: 05/24/2016] [Indexed: 01/05/2023]
Abstract
AIMS Polypharmacy is associated with adverse events and multimorbidity, but data are limited on its association with specific comorbidities in primary care settings. We measured the prevalence of polypharmacy and inappropriate prescribing, and assessed the association of polypharmacy with specific comorbidities. METHODS We did a cross-sectional analysis of 1002 patients aged 50-80years followed in Swiss university primary care settings. We defined polypharmacy as ≥5 long-term prescribed drugs and multimorbidity as ≥2 comorbidities. We used logistic mixed-effects regression to assess the association of polypharmacy with the number of comorbidities, multimorbidity, specific sets of comorbidities, potentially inappropriate prescribing (PIP) and potential prescribing omission (PPO). We used multilevel mixed-effects Poisson regression to assess the association of the number of drugs with the same parameters. RESULTS Patients (mean age 63.5years, 67.5% ≥2 comorbidities, 37.0% ≥5 drugs) had a mean of 3.9 (range 0-17) drugs. Age, BMI, multimorbidity, hypertension, diabetes mellitus, chronic kidney disease, and cardiovascular diseases were independently associated with polypharmacy. The association was particularly strong for hypertension (OR 8.49, 95%CI 5.25-13.73), multimorbidity (OR 6.14, 95%CI 4.16-9.08), and oldest age (75-80years: OR 4.73, 95%CI 2.46-9.10 vs.50-54years). The prevalence of PPO was 32.2% and PIP was more frequent among participants with polypharmacy (9.3% vs. 3.2%, p<0.006). CONCLUSIONS Polypharmacy is common in university primary care settings, is strongly associated with hypertension, diabetes mellitus, chronic kidney disease and cardiovascular diseases, and increases potentially inappropriate prescribing. Multimorbid patients should be included in further trials for developing adapted guidelines and avoiding inappropriate prescribing.
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Affiliation(s)
- Carole E Aubert
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland.
| | - Sven Streit
- Institute of Primary Health Care BIHAM, University of Bern, Switzerland.
| | - Bruno R Da Costa
- Institute of Primary Health Care BIHAM, University of Bern, Switzerland.
| | - Tinh-Hai Collet
- Service of Endocrinology, Diabetes and Metabolism, University Hospital of Lausanne, Switzerland; University of Cambridge Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge, UK.
| | - Jacques Cornuz
- Department of Ambulatory Care and Community Medicine, University of Lausanne, Switzerland.
| | - Jean-Michel Gaspoz
- Department of Community and General Medicine, Geneva University Hospital, Geneva, Switzerland.
| | - Doug Bauer
- Departments of Medicine and Epidemiology and Biostatistics, University of California, San Francisco, United States.
| | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland.
| | - Nicolas Rodondi
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland; Institute of Primary Health Care BIHAM, University of Bern, Switzerland.
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17
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Panagioti M, Stokes J, Esmail A, Coventry P, Cheraghi-Sohi S, Alam R, Bower P. Multimorbidity and Patient Safety Incidents in Primary Care: A Systematic Review and Meta-Analysis. PLoS One 2015; 10:e0135947. [PMID: 26317435 PMCID: PMC4552710 DOI: 10.1371/journal.pone.0135947] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Accepted: 07/29/2015] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Multimorbidity is increasingly prevalent and represents a major challenge in primary care. Patients with multimorbidity are potentially more likely to experience safety incidents due to the complexity of their needs and frequency of their interactions with health services. However, rigorous syntheses of the link between patient safety incidents and multimorbidity are not available. This review examined the relationship between multimorbidity and patient safety incidents in primary care. METHODS We followed our published protocol (PROSPERO registration number: CRD42014007434). Medline, Embase and CINAHL were searched up to May 2015. Study design and quality were assessed. Odds ratios (OR) and 95% confidence intervals (95% CIs) were calculated for the associations between multimorbidity and two categories of patient safety outcomes: 'active patient safety incidents' (such as adverse drug events and medical complications) and 'precursors of safety incidents' (such as prescription errors, medication non-adherence, poor quality of care and diagnostic errors). Meta-analyses using random effects models were undertaken. RESULTS Eighty six relevant comparisons from 75 studies were included in the analysis. Meta-analysis demonstrated that physical-mental multimorbidity was associated with an increased risk for 'active patient safety incidents' (OR = 2.39, 95% CI = 1.40 to 3.38) and 'precursors of safety incidents' (OR = 1.69, 95% CI = 1.36 to 2.03). Physical multimorbidity was associated with an increased risk for active safety incidents (OR = 1.63, 95% CI = 1.45 to 1.80) but was not associated with precursors of safety incidents (OR = 1.02, 95% CI = 0.90 to 1.13). Statistical heterogeneity was high and the methodological quality of the studies was generally low. CONCLUSIONS The association between multimorbidity and patient safety is complex, and varies by type of multimorbidity and type of safety incident. Our analyses suggest that multimorbidity involving mental health may be a key driver of safety incidents, which has important implication for the design and targeting of interventions to improve safety. High quality studies examining the mechanisms of patient safety incidents in patients with multimorbidity are needed, with the goal of promoting effective service delivery and ameliorating threats to safety in this group of patients.
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Affiliation(s)
- Maria Panagioti
- NIHR School for Primary Care Research, Centre for Primary Care, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Jonathan Stokes
- NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre (Greater Manchester PSTRC), Manchester Academic Health Science Centre University of Manchester, Manchester, United Kingdom
| | - Aneez Esmail
- NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre (Greater Manchester PSTRC), Manchester Academic Health Science Centre University of Manchester, Manchester, United Kingdom
| | - Peter Coventry
- NIHR Collaboration for Leadership in Applied Health Research and Care—Greater Manchester and Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Sudeh Cheraghi-Sohi
- NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre (Greater Manchester PSTRC), Manchester Academic Health Science Centre University of Manchester, Manchester, United Kingdom
| | - Rahul Alam
- NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre (Greater Manchester PSTRC), Manchester Academic Health Science Centre University of Manchester, Manchester, United Kingdom
| | - Peter Bower
- NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre (Greater Manchester PSTRC), Manchester Academic Health Science Centre University of Manchester, Manchester, United Kingdom
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18
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Sinnott C, Hugh SM, Boyce MB, Bradley CP. What to give the patient who has everything? A qualitative study of prescribing for multimorbidity in primary care. Br J Gen Pract 2015; 65:e184-91. [PMID: 25733440 PMCID: PMC4337307 DOI: 10.3399/bjgp15x684001] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2014] [Accepted: 09/09/2014] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Using clinical guidelines in the management of patients with multimorbidity can lead to the prescription of multiple and sometimes conflicting medications. AIM To explore how GPs make decisions when prescribing for multimorbid patients, with a view to informing intervention design. DESIGN AND SETTING In-depth qualitative interviews incorporating chart-stimulated recall with purposively sampled GPs in the Republic of Ireland. METHOD Grounded theory analysis with iterative theory development. RESULTS Twenty GPs were interviewed about 51 multimorbid cases. In these cases, GPs integrated information from multiple sources including the patient, specialists, and evidence-based medicine. Difficulties arose when recommendations or preferences conflicted, to which GPs responded by 'satisficing': accepting care that they deemed satisfactory and sufficient for a particular patient. Satisficing was manifest as relaxing targets for disease control, negotiating compromise with the patient, or making 'best guesses' about the most appropriate course of action to take. In multimorbid patients perceived as stable, GPs preferred to 'maintain the status quo' rather than rationalise medications, even in cases with significant polypharmacy. Proactive changes in medications were facilitated by continuity of care, sufficient consultation time, and open lines of communication with the patient, other healthcare professionals, and other GPs. CONCLUSION GPs respond to conflicts in the management of multimorbid patients by making compromises between patient-centred and evidence-based care. These findings will be used to inform interventions that aim to care in multimorbidity.
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Affiliation(s)
- Carol Sinnott
- Department of General Practice, University College Cork, Cork, Ireland
| | - Sheena Mc Hugh
- Department of Epidemiology & Public Health, University College Cork, Cork, Ireland
| | - Maria B Boyce
- Department of Epidemiology & Public Health, University College Cork, Cork, Ireland
| | - Colin P Bradley
- Department of General Practice, University College Cork, Cork, Ireland
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