The rising complexity and burden of multimorbidity in a middle-income country

Insights into the morbidity profiles of epidemiologically excluded COVID-19 patients in primary care settings during the third wave of the pandemic in the Anuradhapura District, Sri Lanka

BACKGROUND

The COVID-19 pandemic has dramatically impacted healthcare systems worldwide, leading to changes in the delivery of healthcare services. A profound effect on the well-being of non-COVID-19 patients has been reported, but limited evidence is available from developing countries. This study aimed to describe the morbidity profiles of epidemiologically excluded COVID-19 patients during the pandemic in the primary care setting of the Anuradhapura District of Sri Lanka.

METHODS

This cross-sectional healthcare institution-based study collected morbidity profiles from six state-owned and five private primary care facilities (PCFs) in the Anuradhapura District during the third wave of the COVID-19 pandemic. Reasons for Encounters (RFEs) were recorded from physically available and epidemiologically excluded COVID-19 patients in a paper-based data format and coded using the International Classification of Primary Care.

RESULTS

Out of 1630 primary care encounters, 187 RFEs were identified. Most patients were females (n = 899, 55%) and in the adult age category (n = 1297, 79%). The median age of the patients was 39 years (interquartile range: 21-55). Older patients were likelier to seek primary care in the state sector (p < .001). Most children presented to the private sector compared to state PCFs (p < 0.001). The majority of females significantly utilised state sector PCFs (p = 0.043). Upper respiratory tract infections (n = 154, 9.00%) were the most common RFE. The highest burden of systemic RFEs was associated with dermatological (n = 294, 18%) and respiratory conditions (n = 274, 16%). More than one-third of adults (n = 487, 37.5%) suffered from a self-reported non-communicable disease (NCD). Hypertension (n = 235, 48%), diabetes mellitus (n = 184, 38%), and dyslipidemia (n = 134, 28%) were the most observed NCDs. Multimorbidity was reported in 195 (40%) adult patients with an NCD.

CONCLUSION

The pandemic has led to a shift in primary care morbidity profiles, with a higher incidence of dermatological and respiratory diseases and NCDs among healthcare seekers. Patients sought care from the state and private sector differently depending on age, sex, and nature of illness. Primary care services must prepare to adapt to changes in healthcare-seeking patterns and morbidity profiles during pandemics to ensure comprehensive care is available on demand.

Hypertension in Sri Lanka: a systematic review of prevalence, control, care delivery and challenges

Hypertension (HTN) is recognized as a major modifiable risk factor for cardiovascular deaths in South Asia. Our aim was to furnish a comprehensive analysis of HTN prevalence, trends, control efforts, awareness, barriers in care delivery and associated factors, based on nationally derived evidence in Sri Lanka. A systematic search of online databases ( PubMed, Web of Science, Scopus ), local journals and repositories yielded 6704 results, of which 106 were included. Prevalence of HTN steadily increased from 23.7% (2005-2006) to 34.8% (2021). Associated factors identified were hyperhomocysteinaemia [odds ratio (OR) 2.80], overweight/obesity (OR 2.02), perceived job stress (OR 2.20-3.02), physical inactivity (OR 2.08-2.80), salt intake more than 5 g/day (OR 2.50), smoking (OR 2.31) and waist-to-height ratio more than or equal to 0.5 (OR 2.23). Cohort studies revealed poor blood pressure control and treatment adherence among patients. Pharmacological ( n  = 4) and nonpharmacological ( n  = 6) interventional studies were few. Studies on knowledge, attitudes and practices demonstrated a lack of public awareness. Despite the high prevalence of HTN in Sri Lanka, many cases remain undiagnosed, underscoring importance of targeted screening programmes and culture-specific public health education programmes.

Predictors of Multimorbidity (Defined as Diabetes + Hypertension) Amongst Males Aged 15-54 in India: An Urban/Rural Split Analysis

Objectives: This study aimed to determine which sociodemographic and lifestyle factors may act as predictors of multimorbidity (defined as diabetes + hypertension) amongst men aged 15-54 within urban and rural areas of India. Methods: Data from the latest 2019-2021 India NFHS-5 survey were utilized. Presumed cases of multimorbidity were defined as men who had DM + HTN. A total of 22,411 men in urban areas and 66,768 rural men were analyzed using mixed-effect multi-level binary logistic regression models. Results: Various predictors were found to have a statistically significant association to multimorbidity. Urban areas: Age, region of residence, wealth, religion, occupation, and BMI. Rural areas: Age, education, region of residence, wealth, occupation, caste, BMI, alcohol consumption, media exposure, and tobacco consumption. Conclusion: Departing from the broad operational definitions often studied within literature, this study provided insight into one of the most prevalent specific multimorbidities across India. The urban/rural split analyses revealed substantial differences in high-risk characteristics across both areas, which have commonly been overlooked. These findings may better inform policymakers and assist in effectively reducing multimorbidity-related burden through area-specific preventative programs.

Effects of home visiting programmes on community-dwelling older adults with chronic multimorbidity: a scoping review

BACKGROUND

Chronic ultimorbidity is the most frequent and serious health problem in older adults. Home visiting programmes could be a strategy with potential benefits. However, there are no scoping reviews to date that examine the effects of home visiting programmes on community-dwelling older adults with chronic multimorbidity.

OBJECTIVE

To examine the effects of home visiting programmes on community-dwelling older adults with chronic multimorbidity.

METHODS

A scoping review was carried out following PRISMA-ScR reporting guidelines. The search was conducted in six databases (PubMed/Medline, Cochrane, CINAHL, Web of Science, Scopus and EMBASE) between October 2021 and April 2022.

RESULTS

Four RCTs with 560 patients were included. The visits were carried out by nurses, nursing students, volunteers, and other healthcare professionals. The interventions varied in the number of visits, frequency, duration of follow-up, and whether or not they were combined with other strategies such as telephone calls. Discrepancies were found in the effects of the interventions on quality of life, self-efficacy, self-rated health, and use and cost of health and social services.

CONCLUSION

This review shows that home visiting programmes could have potential benefits for older adults with chronic multimorbidity. However, its results have been inconclusive. There is a need for high quality studies involving a larger number of patients, in which home visits are the main intervention.

Prevalence of multimorbidity and its associations with hospitalisation or death in Japan 2014-2019: a retrospective cohort study using nationwide medical claims data in the middle-aged generation

OBJECTIVE

To describe the prevalence of multimorbidity and its associations with clinical outcomes across age groups.

DESIGN

Retrospective cohort study using nationwide medical claims data.

SETTING

Carried out in Japan between April 2014 and March 2019.

PARTICIPANTS

N=246 671 Japanese individuals aged 20-74 enrolled in the health insurance were included into the baseline data set for fiscal year (FY) 2014. Of those, N=181 959 individuals were included into the cohort data set spanning FY2014-FY2018.

EXPOSURES

Multimorbidity was defined as having ≥2 of 15 chronic conditions according to the International Classification of Diseases 10th Revision codes of the Charlson Comorbidity Index.

PRIMARY AND SECONDARY OUTCOMES

Primary outcome: the standardised prevalence of multimorbidity across age groups was evaluated using data from FY2014 and extrapolated to the Japanese total population.

SECONDARY OUTCOME

hospitalisation or death events were traced by month using medical claims data and insurer enrolment data. Associations between multimorbidity and 5-year hospitalisation and/or death events across age groups were analysed using a Cox regression model.

RESULTS

The standardised prevalence rate of multimorbidity in the nationwide Japanese total population was estimated to 26.1%. The prevalence rate with age was increased, approximately 5% (ages 20-29), 10% (30-39), 20% (40-49), 30% (50-59), 50% (60-69) and 60% (70-74). Compared with individuals aged 20-39 without multimorbidity, those with multimorbidity had a higher incidence of clinical events in any age group (HR=2.43 (95% CI 2.30 to 2.56) in ages 20-39, HR=2.55 (95% CI 2.47 to 2.63) in ages 40-59 and HR=3.41 (95% CI 3.23 to 3.53) in ages ≥60). The difference in the incidence of clinical events between multimorbidity and no multimorbidity was larger than that between age groups.

CONCLUSIONS

Multimorbidity is already prevalent in the middle-aged generation and is associated with poor clinical outcomes. These findings underscore the significance of multimorbidity and highlight the urgent need for preventive intervention at the public healthcare level.

Psychometric properties of the self-care of chronic illness inventory in Chinese older adults with multiple chronic conditions

BACKGROUND

Existing self-care measures for the Chinese population are specific to single chronic conditions. No generic self-care measures exist for the Chinese population with multiple chronic conditions.

OBJECTIVES

To test the structural validity, concurrent validity and reliability of the Self-care of Chronic Illness Inventory (SC-CII) in Chinese older adults with multiple chronic conditions.

METHODS

This cross-sectional study was reported following the Strengthening the Reporting of Observational Studies in Epidemiology guideline. A diverse sample of Chinese older adults with multiple chronic conditions (n = 240) was recruited. Structural validity was assessed with confirmatory factor analysis. Concurrent validity was investigated with hypotheses testing of the relationships between perceived stress, resilience and self-care. Reliability was assessed with Cronbach's alpha and McDonald's omega. Finally, a simultaneous confirmatory factor analysis was conducted to test the general model with all items and all three subscales.

RESULTS

Confirmatory factor analysis supported the two-factor structure of the self-care maintenance and self-care management subscales and the one-factor structure of the self-care monitoring subscale. Concurrent validity was supported by the significant negative correlation (r ranged from -0.18 to -0.38, p < .01) with perceived stress and the significant positive correlation (r ranged from 0.31 to 0.47, p < .01) with resilience. Reliability estimates ranged from 0.77 to 0.82 across the three subscales. The simultaneous confirmatory factor analysis did not support the more general model with the combined set of items.

CONCLUSION

The SC-CII is valid and reliable for Chinese older adults with multiple chronic conditions. Future cross-cultural assessment should be conducted to investigate the measurement equivalence of the SC-CII in individuals from Western and Eastern cultural groups.

IMPLICATIONS FOR PRACTICE

With the increasing number of older adults in China who are living with multiple chronic conditions and the call for culturally tailored self-care interventions, this self-care measure can be used in geriatric primary care settings, long-term facilities and homes to improve the understanding and practice of self-care in older Chinese adults.

Comorbid status of patients with hypertension

Aim. To establish age and gender characteristics, nosological structure of comorbidity among persons 2099 years with hypertension. Materials and methods. The study is based on data from 21 514 electronic health records of the population (2099 years old) with hypertension, mean age 63.0 years, 68.2% women. Diseases associated with hypertension with a frequency above 10% were analyzed. Results. In the sample of people with hypertension, concomitant diseases were detected in 82.7% of cases, 1 disease accompanies 21.0% of the sample with hypertension, 2 diseases 17.9%, 3 diseases 14.0%, 4+ diseases 29.8%. The frequency of association of hypertension with 1 concomitant disease at the 2029 years is 60.8% of cases, at 3039 years 65.1%, at 4049 years 73.9%, at 5059 years 81.1%, 6069 years 85.8%, 7079 years 87.3%, 80+ years 86.2% of cases. Among women with hypertension, the average number of concomitant diseases is higher compared to men (3.47 vs 2.4 cases; p0.001). Among young and middle-aged people, hypertension in most cases is associated with osteochondrosis, osteoarthritis, chronic pancreatitis, gastritis and duodenitis, retinal diseases, thyroid diseases, the female with hypertension accompanied by benign breast disease and menopausal disorders. Hypertension in the elderly is most often associated with cerebrovascular disease, coronary heart disease, diabetes mellitus, senile cataract, but osteochondrosis and osteoarthritis also do not lose their relevance. Conclusion. The existing system of organization of medical care cannot meet the needs of patients with comorbidity, which indicates the need to reorient medical care towards patient-centered care.

Understanding the processes behind the decisions – GPs and complex multimorbidity decision making

Complex multimorbidity, defined either as three or more chronic conditions affecting three or more different body systems or by the patients General Practitioner (GPs), is associated with various adverse outcomes. Understanding how GPs reach decisions for this complex group of patients is currently under-researched, with potential implications for health systems and service delivery. Schuttner and colleagues, through a qualitative approach, reported that internal factors of individuals (decisions tailored to patients; Primary Care Physician (PCP) consultation style; care planning towards an agreed goal of care), external factors within the environment or context of encounter (patient access to healthcare; organizational structures acting as barriers), and relationship-based factors (collaborative care planning; decisions within a dynamic patient clinician relationship) all influence care planning decisions. There are other important findings which have broader relevance to the literature such as the ongoing separation of physical and mental health which persist even within integrated care systems, GPs continue to prioritize continuity of care and that organizational barriers are reported as factors in clinician decision-making for patients. More broadly, the work has proved valuable in extending previously reported findings surrounding care coordination, and limitation of current guidelines for patients with complex multimorbidity. Work-load in general practice is increasing due to an ageing population, increasing prevalence of multimorbidity and polypharmacy, and transfer of clinical activities from secondary to primary care. The future for GPs is more complexity in the clinic room, understanding how GPs make decisions and how this can be supported is crucial for the sustainability for general practice.

Effective Hospital Care Delivery Model for Older People in Nigeria with Multimorbidity: Recommendations for Practice

The importance of developing an effective action-based model of care for multimorbid patients has become common knowledge, but it remains unclear why researchers in Nigeria have not paid attention to the issue. Hence, this study assessed the quality of health services using the Donabedian model and aimed to recommend an effective hospital care delivery model for older people in Nigeria with multimorbidity. A cross-sectional study using face-to-face data was conducted between October 2021 and February 2022. The reported data were collated, checked, coded, and entered into JISC online survey software and then exported to IBM Statistical Package for Social Science (SPSS) version 27 for analysis, sourced from the University of West London, London, United Kingdom. The data were collected from the outpatient department of four high-volume public secondary hospitals in Niger State (the largest hospital in the three senatorial zones and that of the state capital). Systematic random sampling was used to select 734 patients with two or more chronic diseases (multimorbidity) aged 60 years and above who presented for routine ambulatory outpatient and consented to participate in the study. A Service Availability and Readiness Assessment (SARA) tool was used to assess the structure, and the process quality was assessed by the patients’ experiences as they navigated the care pathway, whereas the outcome was measured using the patients’ overall satisfaction. Using Spearman’s correlation, no statistically significant association was observed between satisfaction level with the healthcare that was received and the five domains of health facility readiness (Total score Basic Amenities, Total score Basic Equipment, Total score infection control, Total score diagnostic capacity, Total score essential drugs), and the general facility readiness. Finally, the process component superseded the structure as the determinant of the quality of healthcare among multimorbid patients in Niger State. The emphasis of the process should be on improving access to quality of care, improving patient–physician relationships and timing, reducing the financial burden of medical care, and building confidence and trust in medical care. Therefore, these factors should be incorporated into designing the healthcare model for multimorbid patients in Nigeria.

Prevalence and patterns of multimorbidity in chronic diseases in Guangzhou, China: a data mining study in the residents' health records system among 31 708 community-dwelling elderly people

OBJECTIVES

Examination of the prevalence, influence factors and patterns of multimorbidity among the elderly people in Guangzhou, China.

DESIGN

Cross-sectional study.

PARTICIPANTS

31 708 community-dwelling elderly people aged 65 and over.

PRIMARY AND SECONDARY OUTCOME MEASURES

Prevalence, influence factors and patterns of multimorbidity in seven chronic conditions among the participants. A multistage, stratified random sampling was adopted for selection of health records in the residents' health records system of Guangzhou. Data mining by association rule mining analysis was used to explore the correlations and multimorbidity patterns between seven chronic diseases.

RESULTS

The prevalence of morbidity was 55.0% (95% CI 40.1% to 60.1%) and the multimorbidity was 15.2% (95% CI 12.4% to 18.4%) among the participants. Elderly, women, higher education level, being single, living in urban areas and having medical insurance were more likely to have chronic diseases and multimorbidity. Data mining by association rule mining analysis reveals patterns of multimorbidity among the participants, including coexistence of hypertension and diabetes (support: 12.5%, confidence: 17.6%), hypertension and coronary heart disease (support: 4.4%, confidence: 5.7%), diabetes and coronary heart disease (support: 1.6%, confidence: 5.7%), diabetes, coronary heart disease and hypertension (support: 1.4%, confidence: 4.4%).

CONCLUSIONS

A high prevalence of morbidity (especially on hypertension and diabetes) and a relatively low multimorbidity of chronic diseases exist in elderly people. Data mining of residents' health records will help for strengthening the management of residents' health records in community health service centres of Guangzhou, China.

Predictors and patterns of polypharmacy in chronic diseases in a middle-income country

Low and middle-income countries (LMIC) are increasingly affected by non-communicable diseases (NCDs), which overburden the health system. With the rising prevalence of multimorbidity, polypharmacy is inevitable. Sri Lanka too faces the burden of polypharmacy and multimorbidity, and it is a strain on the economy as Sri Lankan health care is free-of-charge to all citizens. Therefore, steps to reduce inappropriate polypharmacy are a necessity. The aim of the study was to assess the prevalence and patterns of polypharmacy and its associated factors. In the medical clinics of a tertiary care hospital and a University primary care department, a descriptive cross-sectional study was carried out. Data were extracted from the clinical records of patients over the age of 20 years with a minimum of one NCD diagnosed by either a consultant physician or a consultant family physician. The sample size was 1600. Multimorbidity was present among 63.5% of patients. Polypharmacy (five or more than five drugs) was seen in 36.8% of the patients. Diabetes, hypertension, and coronary heart disease were the commonest of all diseases. Those on more than 11 drugs were found to have diabetes mellitus, hypertension, coronary heart disease, chronic kidney disease, and cardiac failure. 15% of the patients in the primary care setting and 59% of the patients in tertiary care experienced polypharmacy. Multiple regression analysis confirmed that polypharmacy increased with male gender, advancing age, and the degree of multimorbidity. Horizontal and vertical integration of multidisciplinary teams in all disciplines to manage patients is needed to combat inappropriate polypharmacy. This will help in optimizing the management of patients with NCDs.