Multimorbidity in chronic disease: impact on health care resources and costs

Venous excess ultrasound: A mini-review and practical guide for its application in critically ill patients

Advancements in healthcare technology have improved mortality rates and extended lifespans, resulting in a population with multiple comorbidities that complicate patient care. Traditional assessments often fall short, underscoring the need for integrated care strategies. Among these, fluid management is particularly challenging due to the difficulty in directly assessing volume status especially in critically ill patients who frequently have peripheral oedema. Effective fluid management is essential for optimal tissue oxygen delivery, which is crucial for cellular metabolism. Oxygen transport is dependent on arterial oxygen levels, haemoglobin concentration, and cardiac output, with the latter influenced by preload, afterload, and cardiac contractility. A delicate balance of these factors ensures that the cardiovascular system can respond adequately to varying physiological demands, thereby safeguarding tissue oxygenation and overall organ function during states of stress or illness. The Venous Excess Ultrasound (VExUS) Grading System is instrumental in evaluating fluid intolerance, providing detailed insights into venous congestion and fluid status. It was originally developed to assess the risk of acute kidney injury in postoperative cardiac patients, but its versatility has enabled broader applications in nephrology and critical care settings. This mini review explores VExUS’s application and its impact on fluid management and patient outcomes in critically ill patients.

The effect of a team-based service model on treatment processes and outcomes and healthcare usage among people with type 2 diabetes in North Karelia, Finland

AIMS

In North Karelia, Finland, a team-based service model was implemented in primary healthcare (PHC) during 2020. In this model, a healthcare customer contacts a nurse who initiates the service process immediately, possibly consulting or directing customers to other professionals. The effect of this new service model among patients with type 2 diabetes (T2D) was assessed.

METHODS

Data from T2D patients diagnosed by 2016 and still residing in North Karelia in 2023 (N = 6312) were extracted from electronic health records. Diabetes-related contacts with nurses or physicians in PHC and specialised healthcare (SHC) were considered, along with emergency care contacts, measurement activity and levels of glycated haemoglobin (HbA1c) and low-density lipoproteins (LDL) between 2017 and 2022. Annual differences between areas were analysed using logistic and Poisson mixed models.

RESULTS

The team-based service model increased T2D-related PHC remote contacts with nurses for a couple of years, but eventually they decreased to a lower level than before. Additionally, the number of other contacts reduced. It had no effect on measurement activity or treatment levels of HbA1c and LDL.

CONCLUSION

The team-based service model might reduce the number of healthcare contacts among T2D patients, but more evidence is needed on its effectiveness and cost-effectiveness.

Perceptions and experiences of chair-based yoga by older adults with multimorbidity - a qualitative process evaluation of the Gentle Years Yoga randomised controlled trial

BACKGROUND

Yoga is increasingly practised by older adults, with growing evidence for its safety and effectiveness across a range of health conditions common to the age group. This process evaluation, embedded within a randomised controlled trial of chair-based yoga for older adults with multimorbidity, qualitatively explored participants' perceptions and experiences of the chair-based yoga programme.

METHODS

One-to-one interviews and class observations were conducted with a subset of trial participants randomised to receive the 12-week chair-based yoga programme. Interview participants were selectively recruited to represent the demographic breadth of the main trial cohort; one yoga class was observed at each delivery site. Interviews were audio recorded, independently transcribed, and analysed according to longitudinal and thematic analysis.

RESULTS

Twenty-five yoga participants were interviewed once (N = 10) or twice (N = 15), providing a 40-interview data set. Participants were aged 66-91 years (mean age 74 years), 56% female (N = 14), predominantly White British (N = 22, 88%), with 2-8 long term health conditions (mean 4.5 conditions). Four interlinked and overarching themes predominated: perceptions of healthy ageing, delineating yoga and exercise, yoga as an adaptable multifaceted health tool, and patterns of ongoing yoga practice. Participants equated acute symptom presentation, not multimorbidity, with illness, and mostly viewed their health as good. They distinguished yoga from exercise based on its integration of the breath with physical movements, which provided a mental focus unfound in other physical activities. Impact of the yoga programme ranged from minimal to transformative, dependent on meaningful biopsychosocial improvements. Accordingly, continuation of yoga beyond the trial ranged from none to full integration as a multifaceted health management tool.

CONCLUSIONS

Participant experiences of the yoga programme interlinked views on health, ageing, exercise, and sustainable health management. Yoga presented as a safe, acceptable, and adaptable option for non-pharmacological health management in older adults. Impact on biopsychosocial health was variable, and directly linked to participants' longer term yoga engagement. Education of health professionals and activity providers regarding ageist stereotypes of health and ageing, together with the evidence base for the safety and effectiveness of yoga, could support and broaden yoga's reach and engagement among both older adult and multimorbid cohorts.

TRIAL REGISTRATION

ISRCTN ISRCTN13567538. Registered 18 March 2019.

Multimorbidity patterns and function among adults in low- and middle-income countries: a scoping review

OBJECTIVES

To map the scope of available evidence on relationships between multimorbidity patterns and functioning among adults in low- and middle-income countries (LMICs), and describe methods used.

DESIGN

Scoping review guided by a five-step methodological framework and Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews reporting guidelines.

DATA SOURCES

PubMed/MEDLINE, Scopus, EBSCOhost (CINAHL) and Cochrane databases were searched from January 1976 to March 2023, plus reference lists of included studies.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Peer-reviewed full-text articles or conference proceedings of any design, published in English or Afrikaans, involving adults (>18 years) with multimorbidity living in LMICs. Studies had to refer to associations between multimorbid patterns of co-occurrence and functioning. Multimorbidity was defined as the coexistence of ≥2 diseases, including any combination of non-communicable, infectious and mental health conditions.

DATA EXTRACTION AND SYNTHESIS

Data were extracted independently by two reviewers using a piloted form. Findings were synthesised according to methodological approaches, multimorbidity-pattern epidemiology, evidence gaps/limitations and recommendations for future research. The International Classification of Functioning, Disability and Health framework was used to classify functional problems.

RESULTS

Nine studies (total sample size: 62 003) were included, mainly from upper-middle-income Asian countries. Key methodological inconsistencies were identified in defining and operationalising multimorbidity, conditions included in determining patterns, statistical methods for pattern determination and functioning outcome measures. Five main multimorbidity pattern domains emerged: Cardio-Metabolic and Coronary Atherosclerotic, Musculoskeletal, Respiratory and Digestive/Visceral, Degenerative, and Mental Health-Related. Mobility limitations, instrumental activities of daily living, self-care and bowel/bladder problems were consistently linked to all pattern domains.

CONCLUSIONS

The limited and geographically skewed body of literature, along with methodological inconsistencies, hampers a comprehensive understanding of multimorbidity patterns and associations with functioning in LMICs. Future research should explore context-specific multimorbidity definitions, employ transparent methodologies, use standardised measures and incorporate diverse samples to inform tailored interventions and policies.

Non-communicable diseases and their associations with outpatient services utilisation: insight from a population-based survey in Malaysia

OBJECTIVES

Multimorbidity has been recognised as a global public health issue, and individuals with multimorbidity have been found to have high healthcare utilisation. This study aims to estimate the prevalence of non-communicable diseases among adults in Malaysia, identify factors associated with multimorbidity, and assess the association between the number of non-communicable diseases and outpatient services utilisation.

DESIGN AND SETTING

A retrospective secondary data analysis using data from the National Health and Morbidity Survey 2019, a cross-sectional household survey among the population in Malaysia.

PARTICIPANTS

All adults aged 18 years and above.

OUTCOME MEASURES

The two outcome variables were multimorbidity and outpatient services utilisation. Characteristics of respondents and those having multimorbidity were described using complex sample descriptive statistics. We used multivariable logistic regression to determine the associated factors of having multimorbidity and the association between the number of non-communicable diseases and outpatient services utilisation.

RESULTS

Overall, 11 347 respondents were included in the analysis. This study found a prevalence of 11.4 (95% CI=10.43-12.39) for multimorbidity. Age, marital status and working status were the factors associated with multimorbidity. Adults with multimorbidity were high users of outpatient services (20.4%, 95% CI=17.5-23.7), approximately threefold of adults with no non-communicable diseases. In the final model, multimorbidity showed an adjusted OR of 3.28 (95% CI=2.48-4.32) for outpatient services utilisation.

CONCLUSION

Understanding factors associated with multimorbidity and the magnitude of the impact of having multimorbidity towards outpatient services utilisation could help in future planning for healthcare system transformation. The recently launched Health White Paper for Malaysia has emphasised primary healthcare as a critical component to achieve aspirations of the health system, which includes equity and responsiveness. Strengthening primary care services and improving patient navigation across healthcare levels are critical to supporting individuals with multimorbidity. Avenues for further research include exploring a wider range of conditions and assessing the longitudinal impact of multimorbidity on healthcare utilisation and health outcomes.

Length of stay in the pediatrics emergency department and associated factors among pediatrics patients in Eastern Ethiopia public hospital, Ethiopia 2022

INTRODUCTION

Patient length of stay is a crucial measure of the emergency department, and it is a vital indicator of health services to evaluate its efficacy, patient care, organizational management, and health care system. Despite this, there are a few studies conducted on pediatric emergency length of stay in developing countries. Therefore, this study serves as input for evidence of pediatric emergency length of stay and associated factors in public hospitals.

METHODS

An institution-based cross-sectional study was conducted among children who attended in pediatric emergency department of Eastern Ethiopia public hospital from May 01 to Jun 31, 2022. A total of 761 children were selected by systematic sampling technique and interview using structured questionnaires. After data is collected and cleaned, entered using Epi data version 4.6 and then exported to Stata version 14.1 for analysis. Finally, an AOR with a 95% CI was computed, and variables with a P-value < 0.05 in the multivariable analysis were taken as significant factors for prolonged length of stay.

RESULT

The prevalence of prolonged length of stay in the emergency ward was 214 (72%). Living in a rural residence ([AOR = 1.65, 95% CI (1.10-2.48)], having a duration of pain > = 12 ([AOR = 1.92, 95% CI (1.13-3.25)], waiting time > = 5 minute ([AOR = 2.24, 95% CI (1.1-4.248541)], having comorbid illness ([AOR = 1.92, 95%CI, 1.13-3.25)], and higher acuity level and absence of medication in the hospital were ([AOR = 2.26, 95%CI (1.02-2.46]) were significantly associated factors for prolonged length of stay.

CONCLUSION AND RECOMMENDATION

This study revealed that more than two-thirds of children admitted to pediatric emergency had prolonged lengths of stay. This result indicated that higher proportion of the length of stay in pediatric emergency in Eastern Ethiopian public hospitals compare to national. Hence, it is better to give priority to strengthening the focused evaluation of important variables and manage accordingly.

Multimorbidity latent classes in relation to 11-year mortality, risk factors and health-related quality of life in Malaysia: a prospective health and demographic surveillance system study

BACKGROUND

We aimed to identify specific multimorbidity latent classes among multi-ethnic community-dwelling adults aged ≥ 18 years in Malaysia. We further explored the risk factors associated with these patterns and examined the relationships between the multimorbidity patterns and 11-year all-cause mortality risk, as well as health-related quality of life (HRQoL).

METHODS

Using data from 18,101 individuals (aged 18-97 years) from the baseline Census 2012, Health Round 2013, and Verbal Autopsies 2012-2023 of the South East Asia Community Observatory (SEACO) health and demographic surveillance system, latent class analysis was performed on 13 chronic health conditions to identify statistically and clinically meaningful groups. Multinomial logistic regression and Cox proportional hazards regression models were conducted to investigate the adjusted association of multimorbidity patterns with the risk factors and mortality, respectively. HRQoL was analyzed by linear contrasts in conjunction with ANCOVA adjusted for baseline confounders.

RESULTS

Four distinct multimorbidity latent classes were identified: (1) relatively healthy (n = 10,640); (2) cardiometabolic diseases (n = 2428); (3) musculoskeletal, mobility and sensory disorders (n = 2391); and (4) complex multimorbidity (a group with more severe multimorbidity with combined profiles of classes 2 and 3) (n = 699). Significant variations in associations between socio-demographic characteristics and multimorbidity patterns were discovered, including age, sex, ethnicity, education level, marital status, household monthly income and employment status. The complex multimorbidity group had the lowest HRQoL across all domains compared to other groups (p < 0.001), including physical health, psychological, social relationships and environment. This group also exhibited the highest mortality risk over 11 years even after adjustment of confounders (age, sex, ethnicity, education and employment status), with a hazard of death of 1.83 (95% CI 1.44-2.33), followed by the cardiometabolic group (HR 1.42, 95% CI 1.18-1.70) and the musculoskeletal, mobility and sensory disorders group (HR 1.29, 95% CI 1.04-1.59).

CONCLUSIONS

Our study advances the understanding of the complexity of multimorbidity and its implications for health outcomes and healthcare delivery. The findings suggest the need for integrated healthcare approaches that account for the clusters of multiple conditions and prioritize the complex multimorbidity cohort. Further longitudinal studies are warranted to explore the underlying mechanisms and evolution of multimorbidity patterns.

Assessment of older persons with multimorbidity in Norwegian primary care: a qualitative study of healthcare professionals' experiences and preferences in fostering continuity of care

BACKGROUND

As the population ages, more people live longer with multimorbidity. Older people with multimorbidity face diverse needs and medical conditions, increasing the risk of adverse health outcomes, and often experience fragmented healthcare. Research has called for better ways to reach, understand and care for this group to enhance care continuity. This study aimed to examine healthcare professionals' experiences and preferences as they relate to assessments' role in promoting care continuity for home-dwelling older patients with multimorbidity in community-based healthcare.

METHODS

This qualitative study acquired qualitative data from 17 healthcare professionals from reablement teams, interdisciplinary teams, rehabilitation teams and home nursing in three Norwegian municipalities. Representing nursing, physiotherapy, occupational therapy and social work, all participants were experienced in assessing older home-dwelling patients with multimorbidity. Semi-structured focus group and individual interviews were conducted, then the interviews were transcribed and analysed using reflexive thematic analysis.

RESULTS

The analysis elicited three themes: gaining insight beyond diagnoses to promote relational continuity, facilitating interaction to ensure informational continuity, and linking patient journeys to facilitate managerial continuity. The themes underscore the significance of evaluating patients beyond their medical conditions, emphasising assessment's collaborative nature across disciplines. Healthcare professionals use diverse assessment methods and facilitate interaction to understand patients' needs. Working together across different healthcare professions is key for care that includes the whole patient, but challenges such as underutilisation of assessments and poor documentation still exist. Furthermore, linking patient journeys remains difficult due to fragmented services and limited resources. Despite these challenges, assessments were viewed as crucial to care continuity.

CONCLUSIONS

In this qualitative study, healthcare professionals emphasised that assessment is a complex, continuous process due to the fluctuating health of individuals with multimorbidity. Effective instruments and diverse assessment methods are essential to understanding all aspects of patients' health and well-being to ensure care continuity across individual, service, and system levels. Our findings highlight the need for systematic and structured use of assessments to improve interdisciplinary collaboration and personalised care for older individuals with multimorbidity. Understanding the patient journey is crucial for achieving these goals, potentially benefiting healthcare professionals, policymakers, and primary care providers.

Economic Evaluations of Health Service Interventions Targeting Patients with Multimorbidities: A Scoping Literature Review

Introduction

Multimorbid patients have been growing, leading to an exponential increase in healthcare costs and patterns of resource utilization. Despite the heightened interest toward integrated care programs as a response to the complex need of multimorbid patients, economic evaluations of these programs remain scarce. This work investigated the economic evaluations of service interventions targeting multimorbid patients, to identify the characteristics of these programs and the methods applied to their evaluation.

Methods

We conducted a scoping review of papers published between 2010 and 2021 on PubMed, Science Direct, EconLit and Web Of Science. The search strategy was built around three keyword blocks: service interventions, multimorbidity, economic evaluations. We selected economic evaluations of service interventions delivered through multiple care settings and targeting patients with 2+ chronic conditions.

Results

Twenty-five articles were included. Interventions were categorized as organizational-type versus patient-oriented. The selected studies often targeted patients with one chronic disease, associated with a mental disorder, like depression or anxiety. Included studies were mostly cost-utility analyses conducted with the healthcare perspective.

Discussions and conclusions

This work confirmed that economic evaluations of service interventions for multimorbid patients are limited in number. This could suggest that decision-making regarding the delivery of healthcare services for multimorbid patients may not always be based on a solid evidence base. More economic analyses are needed to inform evidence-based coverage decision-making.

The rising cost of infective endocarditis in West Virginia

The financial burden of hospitalization from life-threatening infectious diseases on the U.S. healthcare system is substantial and continues to increase. The purpose of this study was to identify key predictors of high hospital charges for infective endocarditis at a major university-affiliated cardiac care centre in West Virginia.A retrospective electronic medical records' review was undertaken of all adult patients admitted for endocarditis between 2014-2018. Multiple linear regression analysis assessed the total charges billed to the patient account for their endocarditis hospitalization in the medical record.Hospital charges have increased 12-fold during 2014-2018. Among the 486 patients, the median hospital charge was $198 678. About 47% of the patients underwent surgery incurring 70% of the total charges. Patients with hospital stays of ≥50 days accounted for a third of all charges. The multiple linear regression model accounted for 85% of the linear variance in the hospital charges. Median charges increased by 30.87% for patients with ≥9 consultations, 60.32% for those who died in the hospital, and 81.85% for those who underwent surgical intervention.The study findings showed that complex care requiring multiple consultations, surgical interventions, and longer hospital stays were significantly associated with higher hospital charges for endocarditis treatment.

Association between climate change and patient health outcomes: a mixed-methods systematic review

INTRODUCTION

Climate change poses significant threats to the environment, biodiversity, and socioeconomic stability worldwide. Its impact on human health, particularly within healthcare systems, is growing in concern. Nurses, as front-line healthcare workers, play a crucial role in addressing climate-related health risks. However, there is a gap in understanding nursing perspectives on climate change and its implications for patient health outcomes.

AIM

To synthesize empirical evidence on the association between climate change and patient health outcomes from a nursing perspective.

METHODS

A mixed-methods systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The search was carried out in January 2024 in six scientific databases including CINAHL, PubMed, Scopus, ProQuest, Web of Science, and OVID Nursing. Studies focusing on climate change and patient health outcomes from a nursing perspective were included. Data extraction, quality appraisal, and synthesis were performed systematically.

RESULTS

The systematic review included 18 studies of a mainly quantitative nature. Three main themes emerged as follows: Climate Healthcare Interplay; Future Nurses as Agents of Change; and Navigating Sustainability Challenges in Nursing. These themes highlighted nurses' awareness of the interrelation between climate and health, the need for environmental education in nursing, and the challenges that hinder sustainable nursing practices.

CONCLUSION

This review underscores the importance of integrating climate change topics into nursing education and fostering organizational support for sustainable nursing practices. Addressing these challenges is essential for nurses to mitigate the health risks posed by climate change effectively.

The evaluation of a lean healthcare concept to improve the implementation of Digital Health innovations in secondary health care: a qualitative study within a Dutch hospital setting

BACKGROUND

Digital health innovations are considered a promising avenue in transforming the resourcing, organization and delivery of healthcare services and are often nurtured in organization-based innovation labs. One of their biggest challenges is developing effective processes for sifting through ideas. To improve the existing work process, innovation management is often rooted in lean thinking principles. To illustrate the optimization of the efficiency of innovation processes, an example of a lean innovation process concept will be evaluated in this study.

METHODS

The setting of this study was the Health Innovation Lab (HIL) of the Maastricht University Medical Center + (MUMC +) in the Netherlands. The aim was to evaluate its lean "speed dating" concept to improve the implementation of Digital Health innovations in secondary health care. A qualitative study was performed based on a focus group and semi-structured interviews. 36 stakeholders were selected by purposive sampling. Data was collected from 11 respondents. The transcripts of the focus group and interviews were coded according to the open and axial coding phases of the methods of Grounded Theory.

RESULTS

Five major themes emerged during the thematic analysis of the transcriptions: (1) Preparation before the Sign in, (2) Mapping out the process between Sign in and Sign out, (3) Defining the roles and deliverables of experts, (4) Guiding the idea owner, and (5) Supporting capacity of resources.

CONCLUSIONS

Through multidisciplinary interaction, by encouraging creative thinking and by fostering innovative behavior, innovation labs cultivate the development of innovative solutions. While the creative phase of innovation commonly exhibits non-linearity, most innovation pilots and implementations follow a linear path. This linearity seems to contradict the importance of flexible approaches to prevent waste in the context of innovation. However, our results suggest that improving cooperation between stakeholders may be a strategy to mitigate this effect. This paper broadens the knowledge on how multidisciplinary interaction during a lean innovation process can be improved, thereby enhancing the implementation of DH innovations.

Prevalence and Factors Associated with a High Risk of Malnutrition among Older Adults in the East Coast of Peninsular Malaysia

Background

Older people are more susceptible to malnutrition. Malnutrition is defined as imbalances and deficiencies of nutrients that result in diminished function. However, malnutrition identification through nutrition screening is not routinely performed at Malaysian health clinics or hospitals. Our study aimed to determine the proportion of older people at high risk of malnutrition and its associated factors.

Methods

This was a cross-sectional study conducted among older persons aged ≥ 60 years, and the exclusion criteria were older persons with known cases of dementia or the inability to stand and have hand problems that limit the ability to hold the dynamometer. Sociodemographic data and anthropometry assessment were conducted. Malnutrition risk screening tool-hospital, modified Barthel Index and the Elderly Cognitive Assessment Questionnaire were used in this study. The data were analysed using descriptive statistics and multiple logistic regression.

Results

A total of 200 older persons participated in the study, and the proportion of the high risk of malnutrition was 27 (13.5%). Poor handgrip strength odd ratio (OR) = 3.56, 95% confidence interval (CI) = 1.41, 8.98; p = 0.007) and living arrangements (OR = 4.6, 95% CI = 1.31, 16.1; p = 0.017) were significantly associated with a high risk of malnutrition in older persons.

Conclusions

The proportion of older persons at high risk of malnutrition was low (13.5%). Poor handgrip strength and living arrangements are significant factors associated with a high risk of malnutrition among older persons. Nutrition screening can help identify the cause and other factors of malnutrition. The role of healthcare personnel should be emphasised in nutrition screening, as they are commonly the first point of contact for patients seeking medical advice.

Agreement and disagreement in pediatric functional neurological symptom disorders: Comparing patient reported outcome measures (PROMs) and clinician assessments

Youth with functional neurological symptom disorder (FNSD) often perceive themselves as having limited capabilities, which may not align with clinical evaluations. This study assessed the disparities between clinician evaluations and patient-reported outcome measures (PROMs) regarding pain, motor function, and learning difficulties in youth with FNSD. Sixty-two youths with FNSD participated in this study, all of whom reported experiencing pain, motor problems, and/or learning difficulties. Clinicians also assessed these domains, resulting in a two-by-two categorization matrix: (1) agreement: child and clinician report "problems"; (2) agreement: child and clinician report "no problems"; (3) disagreement: child reports "problems" while the clinician does not; and (4) disagreement: clinician reports "problems" while the child does not. Agreement/disagreement differences were analyzed. No significant differences in prevalence were observed between the evaluators regarding pain (clinician-85%, child-88%), motor (clinician-98%, child-95%), or learning problems (clinician-69%, child-61%). More than 80% of the children and clinicians report pain and motor disorders. Instances in which children and clinicians reported learning problems (40.3%) exceeded cases in which both reported no problems (9.6%) or only the child reported problems (20.9%). Overall, the agreement between pain and motor function assessments was high (>90%), whereas that concerning learning difficulties was moderate (49.9%). Disagreement in pain/motor assessments was minimal (<5%), whereas for learning difficulties, disagreement rates were high (>20%). In conclusion, a significant concordance exists between PROMs and clinician assessments of pain and motor problems. However, the higher frequency of disagreements regarding learning difficulties emphasizes the importance of incorporating patient and clinician evaluations in pediatric FNSD treatment.

Complex patterns and determinants of regional multiple chronic conditions across the United States

Noncommunicable chronic diseases (NCDs) are a rapidly growing global public health concern, posing substantial challenges to healthcare systems. The presence of multiple (≥2) chronic conditions (MCC) exacerbates these challenges. In this study, we constructed an integrated MCC network to comprehensively evaluate the impact of NCD prevalence and associated factors on MCC patterns. We identified four distinct MCC patterns, each with its unique set of associated risk factors. Firstly, we found that race, sedentary lifestyles, and smoking habits were significant contributors to the co-occurrence of diabetes, chronic kidney disease, and cancer. Secondly, smoking habits and mental health were identified as risk factors associated with the clusters of high cholesterol, hypertension, coronary heart disease, and arthritis. Furthermore, the comorbidity of chronic obstructive pulmonary disease and asthma was affected by socioeconomic status, smoking habits, and educational attainment, and a noteworthy reciprocal relationship existed between these two MCC combinations. Thirdly, the combination of asthma and obesity is associated with risk factors such as mental health, smoking habits, sedentary lifestyles, and binge drinking behaviors. Finally, the pattern of depression-stroke comorbidity was influenced by risk factors including mental health, age, and sleep duration. Our findings hold valuable implications for healthcare system optimization, offering a pathway to mitigate the escalating burden of NCDs. Additionally, they provide a foundation for scientific strategies aimed at the joint prevention and management of these complex conditions, ultimately enhancing public health and safety on a global scale.

Factors influencing diabetes treatment satisfaction in the INtegrating DEPrEssioN and Diabetes treatmENT randomized clinical trial: A multilevel model analysis

AIMS

Patient satisfaction is associated with positive diabetes outcomes. However, there are no identified studies that evaluate both patient- and clinic-level predictors influencing diabetes care satisfaction longitudinally.

METHODS

Data from the INtegrating DEPrEssioN and Diabetes treatmENT trial was used to perform the analysis. We used fixed and random effects models to assess whether and how changes in patient-level predictors (treatment assignment, depression symptom severity, systolic blood pressure, body mass index, LDL cholesterol, and haemoglobin A1C) from 0 to 24 months and clinic-level predictors (visit frequency, visit cost, number of specialists, wait time, time spent with healthcare provider, and receiving verbal reminders) measured at 24 months influence diabetes care satisfaction from 0 to 24 months.

RESULTS

Model 1 (patient-level predictors) accounted for 7% of the change in diabetes satisfaction and there was a significant negative relationship between change in depressive symptoms and care satisfaction (β = -0.23, SE = 0.12, p < 0.05). Within Model 1, 2% of the variance was explained by clinic-level predictors. Model 2 included both patient- and clinic-level predictors and accounted for 18% of the change in diabetes care satisfaction. Within Model 2, 9% of the variance was attributed to clinic-level predictors. There was also a cross-level interaction where the change in depression had less of an impact on the change in satisfaction for those who received a verbal reminder (β = -0.11, SE = 0.21, p = 0.34) compared with those who did not receive a reminder (β = -0.62, SE = 0.08, p < 0.01).

CONCLUSIONS

Increased burden of depressive symptoms influences diabetes care satisfaction. Clinic-level predictors also significantly influence diabetes care satisfaction and can reduce dissatisfaction in primary care, specifically, reminder calls from clinic staff.

Barriers and facilitators for strengthening primary health systems for person-centred multimorbid care in low-income and middle-income countries: a scoping review

OBJECTIVE

To understand barriers and facilitators for strengthening health systems for person-centred care of people with multiple long-term conditions-multimorbidity (MLTC-M) at the primary healthcare (PHC) level in low-income and middle-income countries (LMICs).

DESIGN

A scoping review.

METHODS

We adopted a systematic scoping review approach to chart literature guided by Arksey and O'Malley's methodological framework. The review focused on studies conducted in LMICs' PHC settings from January 2010 to December 2023. Papers were extracted from the following databases: PubMed, EBSCOhost and Google Scholar. Framework analysis was undertaken to identify barriers and facilitators for strengthening MLTC-M primary care according to the five health system pillars in the Lancet Global Health Commission on High-Quality Health Systems Framework.

RESULTS

The literature search yielded 4322 citations, evaluated 202 studies and identified 36 for inclusion. Key barriers within the people pillar included poverty, low health education and low health literacy; within the platform pillar, fragmented services and lack of multimorbid care guidelines were mentioned; within the workforce pillar, lack of required skills and insufficient health workers; and in the tools pillar: a shortage of essential medicines and adverse polypharmacy effects were prominent. A lack of political will and the absence of relevant national health policies were identified under the governance pillar. Facilitators within the people pillar included enhancing self-management support; within the platforms, pillar included integration of services; within the tools pillar, included embracing emerging technologies and information and communication technology services; and governance issues included upscaling interventions to respond to multimorbid care needs through enhanced political commitment and financial support.

CONCLUSIONS

Potential solutions to strengthening the healthcare system to be more responsive to people with MLTC-M include empowering service users to self-manage, developing multimorbid care guidelines, incorporating community health workers into multimorbid care efforts and advocating for integrated person-centred care services across sectors. The need for policies and procedures in LMICs to meet the person-centred care needs of people with MLTC-M was highlighted.

Community Pharmacists' Knowledge in Managing Minor Ailments: A Focus on Childhood Gastroenteritis in Saudi Arabia Using a Simulated Patient Approach

Background: Community pharmacists are frequently approached by patients seeking health advice for minor ailments, particularly for common childhood diseases like diarrhea. Globally, approximately two million children under five years of age die each year due to diarrhea, which remains a significant health concern, especially in developing countries. Objectives: The purpose of this study was to assess the skills of community pharmacists in addressing and prescribing for simple viral diarrhea in children. Methods: A hundred community pharmacies were visited by simulated clients following a standard scenario of inquiring about simple childhood diarrhea. Subsequently, they filled out a standardized form after each visit to assess the skills of the community pharmacists. Results: It was found that 98% of the pharmacists were males. Approximately 80% of them inquired about the child's age, while only 29% asked about the presence of fever. Around 2-6% of them only asked about the stool nature, child's feeding behavior, and family symptoms. Around 10% of them suggested a potential bacterial origin, and 24% recommended the use of antibiotics. Only 43% of the community pharmacists suggested the use of oral rehydration solution, while 15-56% recommended using antidiarrheals, anti-emetics, and spasmolytics. The mean knowledge score of the pharmacists was 9.06 out of 17. Conclusions: The results indicated a relatively low level of knowledge about managing simple viral childhood diarrhea, which may reflect a similar level of knowledge about dealing with minor ailments in general.

Intensity of care and the health status of caregivers to elderly rural South Africans

Objectives

Informal caregivers play an indispensable role in and are often the sole source of care for older adults in low and middle-income settings worldwide. Intensive informal care predicts mortality and morbidity among caregivers in higher-income settings. However, there is limited evidence from poorer settings, including Africa countries, where caregiving is shared widely, including across generations. We therefore investigated caregivers' health status in rural South Africa.

Methods

We conducted quantitative interviews with all household members and all non-household caregivers aged ≥12 (n=1012) of 106 older adults in rural Mpumalanga, South Africa. We used multivariable regression with care-recipient random intercepts to assess the relationships between four caregiving characteristics and both self-reported chronic conditions and self-reported health status, considering how caregiver age moderated each association.

Results

Over half of all caregivers reported at least one chronic health condition, despite half being aged under 40. Caregivers self-reporting the worst health status provided high hours of care. However, caregivers' health status was not significantly associated with weekly care quantity or history of caring. Those aged ≥40 who reported being a main caregiver had 52% increased odds of reporting poorer health compared to other same-aged carers (95% confidence interval: 0.99, 2.35), while having more chronic conditions was associated with being expected to act as a sole caregiver more often among caregivers aged ≤39.

Discussion

Greater caring responsibilities for older adults were not consistently associated with caregivers' health in a setting where poor health is common, and caregiving is spread widely. Longitudinal data is necessary to unpack possible explanations of these findings, and to determine whether intensive caregiving speeds downward health trajectories for carers.

Delayed Healthcare Due to Cost Among Adults with Multimorbidity in the United States

BACKGROUND/OBJECTIVES

Multimorbidity, defined as two or more chronic diseases co-occurring in an individual, has been linked to elevated healthcare utilization and out-of-pocket expenses. Yet, the barriers to healthcare access due to the health profile of multimorbid adults are underexplored. This study investigates the differences in delayed healthcare due to cost among adults with multimorbidity and those with one chronic disease condition.

METHODS

Data from the National Health Interview Survey from the years 2016-2018 and 2020-2021 were examined. The sample included 13,439 adults with at least one of the chronic disease conditions outlined by the US Department of Health and Human Services. Logistic regression models were used to estimate odd ratios of delayed healthcare due to cost among participants.

RESULTS

Multimorbid adults were 1.29 times more likely to delay healthcare compared to adults living with one chronic disease (p < 0.01). Other influencing factors include being female, Asian, unmarried, uninsured, age, worsening self-rated health, region, and poverty threshold of 100-199%.

CONCLUSIONS

Our findings highlight the disparities in healthcare success experienced by adults living with multimorbidity and indicate the need for policymakers to implement targeted measures such as subsidized costs for comorbidities to alleviate the financial burdens experienced by this population.

2024 AAHA Community Care Guidelines for Small Animal Practice

Community care is a creative way of thinking about health care that mobilizes resources within a community and consists of four core principles: recognition of the urgency of access-to-care for the veterinary profession, collaboration within community networks, family-centered health care, and redefining the gold standard of care. The AAHA Community Care Guidelines for Small Animal Practice offer strategies to help busy veterinary practitioners increase access to care within their practice and community by optimizing collaborative networks. While these guidelines do not claim to provide exhaustive solutions to access-to-care issues, they propose a starting point from which private practices can explore and implement workable solutions for their community and their practice. Broadening the scope of care to reach all people with pets requires multimodal, collaborative, and creative solutions both within and outside of the veterinary profession. These solutions can begin with greater communication and collaboration between private veterinary practices and nonprofit veterinary practices, with the goal of keeping pets in their homes with their loving families as much as reasonably possible.

Diabetes in axial spondyloarthritis: a systematic review and meta-analysis of observational studies

Axial spondyloarthritis (axSpA) is a chronic inflammatory condition with an increased risk of cardiovascular disease (CVD). Diabetes is a well-established risk factor for CVD and stroke. The objective of this study was to conduct a systematic review to: (i) identify the prevalence of diabetes in axSpA and (ii) compare the risk of diabetes in patients with axSpA and without. A comprehensive literature search was performed for articles published between 1 January 2000 and 15 November 2023 using Medline, Embase and Scopus (PROSPERO: CRD42023482573). Observational studies reporting prevalence, incidence or risk of diabetes in axSpA were included. Search results were independently screened by at least two reviewers. Quality of included studies were assessed using the JBI critical appraisal tool. Study-specific proportions and odds ratios (OR) were combined in a random-effects meta-analysis. 2257 articles were identified from database searching from which 23 studies were included for analysis amounting to a combined sample size of 65 025 patients. The pooled prevalence of diabetes in people with axSpA was 7.0% (95% CI 5.9-8.0%; predictive interval 2.4-12.9%; p < 0.001). The funnel plot was symmetric suggesting no small-study effects (I2 = 98.1% (95% CI 0.05-0.08), τ2 = 0.02; p < 0.001). Comparing patients with axSpA to those without, the pooled OR was 1.29 (95% CI 1.10-1.52; predictive interval 0.76-2.22; p = 0.001) for diabetes. The study suggests an increased prevalence and probably an increased risk of diabetes in people with axSpA. Routine screening for diabetes and lifestyle modifications should be encouraged in this cohort.

Scaling up integrated care: Can community hospitals be an answer? A multiple-case study from the Emilia-Romagna region in Italy

Integrated care is considered to be essential in improving care for people with chronic conditions who need continuous care. In 2022, the Italian Government asked all regions to build or renovate a massive number of community care facilities, employing European Next Generation funds, to be spent by 2026. Under the theoretical lens of the Structural Contingency Theory, the paper aims at aims at describing the contextual and organizational factors underlying the interconnection between integrated care and community hospitals. The study employs a multiple-case study design, relying both on quantitative and qualitative data, conducted in a 6 months-period. It investigated seven community hospitals belonging to a single Local Health Authority in Emilia-Romagna region in Italy. The choice of the empirical context was driven by Emilia-Romagna's long- and well-established tradition of community-based care. Overall, our analysis shows that community hospitals offers opportunities of integrated care, including better integration between care sectors, between primary care and specialist staff, between healthcare structures and their local community. The study confirms the value of the Structural Contingency Theory and its key message: implementation is not a mechanical step of the policy cycle and requires important adjustments to the planning phase according to environment and organizational factors.

Determinants of medication non-adherence among patients with chronic diseases at community pharmacy settings in South Gondar Zone, Northwest Ethiopia: a multicenter cross-sectional study

Background

Medication non-adherence is a significant public health concern in managing patients with chronic diseases, and community pharmacists are on the frontline in the management of chronic medications. Chronic diseases require lifelong pharmacotherapy and understanding the determinants of medication adherence has paramount importance to develop strategies that improve medication adherence and treatment outcomes. Thus, this study aimed to assess the magnitude of medication non-adherence and its contributing factors among patients with chronic diseases attending community pharmacies in South Gondar Zone, Northwest Ethiopia.

Methods

A multicenter cross-sectional study was conducted at community pharmacies in South Gondar Zone from September 01 to October 30, 2023. Medication adherence was assessed using a structured questionnaire using the Adherence in Chronic Diseases Scale (ACDS). Statistical Package for Social Sciences (SPSS) version 25 was used for analysis. Association between the outcome variable and independent variables was performed using binary logistic regression and a p-value of <0.05 was considered statistically significant.

Results

Among three hundred and eighty six (386) study participants recruited in this study, more than half of them 222 (57.51%, 95%CI: 52.4% - 62.5%) were low adherent to their medications. Concerning determinants of medication non-adherence; the presence of side effects (AOR =2.1, 95%CI=1.33-3.29), unable to get ever counseling from community pharmacists (AOR=2.3, 95%CI= 1.46-3.58), and poor about their medications (AOR=3.1, 95% CI= 1.96-4.82) were significantly associated with patients' non-adherence to medications.

Conclusion

The medication adherence level in this study was suboptimal, with a significant proportion of the patients being non-adherent to their medications. The presence of side effects, unable to get ever counseling, and poor knowledge about their medications were statistically significant factors of poorer medication adherence. Hence, healthcare professionals, especially community pharmacists, have a crucial role in designing the schedule for health education concerning the needs of these patients in community pharmacy settings.

Priorities for multimorbidity management and research in cancer: a Delphi study of Australian cancer survivors, clinicians, and researchers

PURPOSE

Multimorbidity is common in people with cancer and associated with increased complexity of care, symptoms, mortality, and costs. This study aimed to identify priorities for care and research for cancer survivors with multimorbidity.

METHODS

A Delphi consensus process was conducted. Elements of care and research were based on Australia's National Strategic Framework for Chronic Conditions, a literature review, and expert input. In Round 1, health professionals, cancer survivors, and researchers rated the importance of 18 principles, 9 enablers, and 4 objectives. In Round 2, new elements were rated and all elements were ranked.

RESULTS

In Round 1, all elements reached consensus for care delivery; three principles and one enabler did not reach consensus for research and were eliminated. One principle and two enablers were added, reaching consensus. In the final list, 19 principles, 10 enablers, and 4 objectives were included under care delivery; 14 principles, 9 enablers, and 4 objectives were included under research. For care delivery, principles of 'survivorship' and 'self-management' were ranked highest, and 'peer support' and 'technology' were the most important enablers. For research, 'survivorship' and 'coordinated care' were the highest-ranked principles, with 'peer support' and 'education' the most important enablers.

CONCLUSION

Most elements apply to the general population and cancer survivors; however, additional elements relevant to survivorship need consideration when managing multimorbidity in cancer survivors.

IMPLICATIONS FOR CANCER SURVIVORS

Chronic disease frameworks should be more inclusive of issues prioritised by people with, managing, or researching cancer through interdisciplinary approaches including acute and primary care.

Care Quality and Equity in Health Centers During and After the COVID-19 Pandemic

INTRODUCTION

Federally Qualified Community Health Centers (FQHCs) are on the frontline of efforts to improve healthcare equity and reduce disparities exacerbated by the COVID-19 pandemic. This study assesses the provision and equity of preventive care and chronic disease management by FQHCs before, during, and after the pandemic.

METHODS

Using electronic health record data from 210 FQHCs nationwide and employing segmented regression in an interrupted time series design, preventive screening and chronic disease management were assessed for 939,053 patients from 2019 to 2022. Care measures included cancer screenings, blood pressure control, diabetes control, and childhood immunizations; patient-level factors including race and ethnicity, language preference, and multimorbidity status were analyzed for equitable care provision. Analyses were conducted in 2023-2024.

RESULTS

Cancer screening rates and blood pressure control initially declined after the onset of the pandemic but later rebounded, while diabetes control showed a slight increase, later stabilizing. Racial and ethnic disparities persisted, with Asian individuals having a higher prevalence of screenings and blood pressure control, and Black/African American individuals facing a lower prevalence for most screenings but a higher prevalence for cervical cancer screening. Hispanic/Latino individuals had a higher prevalence of various screenings and diabetes control. Disparities persisted for Native Hawaiian/Other Pacific Islander and American Indian/Alaska Native individuals and were observed based on language and multimorbidity status.

CONCLUSIONS

While preventive screening and chronic disease management in FQHCs have largely rebounded to pre-pandemic levels following an initial decline, persistent disparities highlight the need for targeted interventions to support FQHCs in addressing healthcare inequities.

Chronic disease incidence explained by stepwise models and co-occurrence among them

Multimorbidity (MM) is the co-occurrence of two or more chronic diseases. We provided a dynamic approach revealing the MM complexity constructing a multistep incidence-age model for all patients with MM between 2014 and 2021 in the Basque Health System, Spain. The multistep model, with eight steps for males and nine for females, is a very well-fitting representation of MM. To gain insight into the MM components, we modeled the 19 diseases used to calculate the Charlson Comorbidity Index (CCI). We observed that the CCI diseases formed a complex interaction network. Hierarchical clustering of the incidence-age profiles clustered the CCI diseases into low- and high-risk of dying pathologies. Diseases with a higher number of steps are better represented by a multistep model. Anatomically, diseases associated with the central nervous system have the highest number of steps, followed by those associated with the kidney, heart, peripheral vasulature, pancreas, joints, cerebral vasculature, lung, stomach, and liver.

Clinical outcomes after idecabtagene vicleucel in older patients with multiple myeloma: a multicenter real-world experience

ABSTRACT

The safety and efficacy of chimeric antigen receptor T-cell therapy is not well described in older patients, a population that has higher frailty and comorbidities. In this multicenter retrospective study, we evaluated clinical outcomes along with frailty and geriatric characteristics such as comorbidities, polypharmacy, falls, neuropathy, organ dysfunction, and performance status in younger (aged <65 years) vs older (aged ≥65 years) patients who received commercial idecabtagene vicleucel (ide-cel). A total of 156 patients (n = 75, aged ≥65 years) were infused with ide-cel by data cutoff. In older patients (median age: 69 years; range, 65-83; 66.7% frail; 77.3% did not meet KarMMa eligibility criteria), with a median follow-up duration of 14.2 months, best overall response rate (ORR) was 86.7%, which was comparable with pivotal KarMMa study results (ORR: 73%). Median progression-free survival and overall survival in older patients were 9.1 months and 26.5 months, respectively. Grade ≥3 cytokine-release syndrome and immune effector cell-associated neurotoxicity syndrome were observed in 1% and 4% of older patients, respectively. Compared with younger patients, the older patients had significantly higher prevalence of frailty, geriatric characteristics such as polypharmacy (≥5 drugs; 97%), ≥4 comorbidities (69%), and organ dysfunction (35%; P < .05). The safety and efficacy of ide-cel therapy were similar in younger and older patients. Frailty and geriatric characteristics such as polypharmacy, comorbidities, and organ dysfunction in older patients did not confer an inferior overall outcome.

Chair-based yoga programme for older adults with multimorbidity: RCT with embedded economic and process evaluations

Background

Older adults with multimorbidity experience impaired health-related quality of life and treatment burden. Yoga has the potential to improve several aspects of health and well-being. The British Wheel of Yoga's Gentle Years Yoga© programme was developed specifically for older adults, including those with chronic conditions. A pilot trial demonstrated feasibility of using Gentle Years Yoga in this population, but there was limited evidence of its effectiveness and cost-effectiveness.

Objective

To determine the effectiveness and cost-effectiveness of the Gentle Years Yoga programme in addition to usual care versus usual care alone in older adults with multimorbidity.

Design

Pragmatic, multisite, individually randomised controlled trial with embedded economic and process evaluations.

Setting

Participants were recruited from 15 general practices in England and Wales from July 2019 with final follow-up in October 2022.

Participants

Community-dwelling adults aged 65 years and over with multimorbidity, defined as two or more chronic health conditions from a predefined list.

Interventions

All participants continued with any usual care provided by primary, secondary, community and social services. The intervention group was offered a 12-week programme of Gentle Years Yoga.

Main outcome measures

The primary outcome and end point were health-related quality of life measured using the EuroQol-5 Dimensions, five-level version utility index score over 12 months. Secondary outcomes were health-related quality of life, depression, anxiety, loneliness, incidence of falls, adverse events and healthcare resource use.

Results

The mean age of the 454 randomised participants was 73.5 years; 60.6% were female, and participants had a median of three chronic conditions. The primary analysis included 422 participants (intervention, n = 227 of 240, 94.6%; usual care, n = 195 of 214, 91.1%). There was no statistically or clinically significant difference in the EuroQol-5 Dimensions, five-level version utility index score over 12 months: the predicted mean score for the intervention group was 0.729 (95% confidence interval 0.712 to 0.747) and for usual care it was 0.710 [95% confidence interval (CI) 0.691 to 0.729], with an adjusted mean difference of 0.020 favouring intervention (95% CI -0.006 to 0.045, p = 0.14). No statistically significant differences were observed in secondary outcomes, except for the pain items of the Patient-Reported Outcomes Measurement Information System-29. No serious, related adverse events were reported. The intervention cost £80.85 more per participant (95% CI £76.73 to £84.97) than usual care, generated an additional 0.0178 quality-adjusted life-years per participant (95% CI 0.0175 to 0.0180) and had a 79% probability of being cost-effective at the National Institute for Health and Care Excellence threshold of £20,000 per quality-adjusted life-year gained. The intervention was acceptable to participants, with seven courses delivered face to face and 12 online.

Limitations

Self-reported outcome data raise the potential for bias in an unblinded trial. The COVID-19 pandemic affected recruitment, follow-up and the mode of intervention delivery.

Conclusions

Although the Gentle Years Yoga programme was not associated with any statistically significant benefits in terms of health-related quality of life, mental health, loneliness or falls, the intervention was safe, acceptable to most participants and highly valued by some. The economic evaluation suggests that the intervention could be cost-effective.

Future work

Longer-term cost-effectiveness modelling and identifying subgroups of people who are most likely to benefit from this type of intervention.

Trial registration

This trial is registered as ISRCTN13567538.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 17/94/36) and is published in full in Health Technology Assessment; Vol. 28, No. 53. See the NIHR Funding and Awards website for further award information.

Age-specific Multimorbidity Patterns and Burden on All-Cause Mortality and Public Direct Medical Expenditure: A Retrospective Cohort Study

OBJECTIVE

To evaluate age-specific multimorbidity patterns and morbidity burden on mortality and healthcare expenditure across age groups.

PATIENTS AND METHODS

Retrospective observational study between January 1, 2009 to December 31, 2017 using electronic health records in Hong Kong: Individuals were stratified by age (< 50, 50-64, 65-79, ≥ 80), and sub-classified by number of morbidities (0, 1, 2, 3, ≥ 4) out of 21 common chronic conditions. Clustering analyses were conducted to identify specific patterns of multimorbidity. Association between the number as well as combinations of morbidities and all-cause mortality and public expenditure was examined.

RESULTS

4,562,832 individuals with a median follow-up of 7 years were included. Mental disorders were the top morbidities among young individuals, while cardiovascular diseases were prevalent in the elderly. An increased number of morbidities was associated with a greater relative risk for mortality and medical expenditure, and this relationship was stronger among younger patients. Compared to individuals in the same age group without morbidity, the hazard ratios (HR; 95% CI) of all-cause mortality in patients aged < 50 and ≥ 80 with two comorbidities 3.81 (3.60-4.03) and 1.38 (1.36-1.40), respectively, which increased to 14.22 (9.87-20.47) and 2.20 (2.13-2.26), respectively, as the number of morbidities increased to ≥ 4. The stroke-hypertension cluster was shown to be associated with the highest HR of mortality 2.48 (2.43-2.53) among all identified clusters arising from the clustering analysis.

CONCLUSION

Given the stronger association between multimorbidity and all-cause mortality and greater opportunity costs in younger populations, prevention and management of early-onset multimorbidity are warranted. (248 words).

Navigating the Health Care Landscape for an Ageing Population: An International Survey of Strategies and Priorities

OBJECTIVES

The global increase in the older population, which is expected to reach 1.5 billion by 2050, poses significant challenges for publicly funded health care systems. Life expectancy, although positive, is leading to an increase in chronic diseases requiring complex and costly health and social solutions. This study explores key strategies to address these challenges.

DESIGN

Qualitative interviews followed by a survey.

SETTING AND PARTICIPANTS

The study involved experts, students, artificial intelligence, and participants at a congress.

METHODS

We first interviewed 5 experts from different countries representing health care management and psychology from Belgium, health economics from Canada, sociology from France, and geriatrics from Switzerland. In addition, a focus group session with medical students in physical therapy and queries to ChatGPT increased the range of perspectives. A synthesis of all opinions or insights was used to formulate concrete strategies. These strategies were incorporated into an online survey that was distributed to 215 participants of the Geriatric and Gerontologic Congress in Montreal, Canada, in September 2023.

RESULTS

All 20 potential solutions were duly acknowledged, with particular attention paid to the following 5 priorities: the urgent need to integrate geriatric training into the education of future health professionals, the promotion of home-based care models, the establishment of comprehensive and integrated care systems, the strengthening of primary care services, and the emphasis on primary prevention strategies.

CONCLUSION AND IMPLICATIONS

This study highlights key priorities for addressing the health needs of the older population. By emphasizing education, home-based care, and integrated services and strengthening primary care and prevention, health systems can respond effectively to the challenges of an ageing population. Although these needs may not be entirely unmet, they indicate areas where existing services are insufficient in providing adequate coverage and support to ensure tailored and sustainable health care solutions for older people.

Patient Factors Associated with Missed Otolaryngology Appointments at an Urban Safety-Net Hospital

OBJECTIVE

To determine if patient factors related to ethnicity, socioeconomic status (SES), medical comorbidities, or appointment characteristics increase the risk of missing an initial adult otolaryngology appointment.

METHODS

This study is a retrospective case control study at Boston Medical Center (BMC) in Boston, Massachusetts, that took place in 2019. Patient demographic and medical comorbidity data as well as appointment characteristic data were collected and compared between those that attended their initial otolaryngology appointment versus those who missed their initial appointment. Chi-square and ANOVA tests were used to calculate differences between attendance outcomes. Multivariate analysis was used to compare the odds of missing an appointment based on various patient- and appointment-related factors.

RESULTS

Patients who were more likely to miss their appointments were more often female, of lower education, disabled, not employed, Black or Hispanic, and Spanish-speaking. Spring and Fall appointments were more likely to be missed. When a multivariate regression was conducted to control for social determinants of health (SDOH) such as race, insurance status, employment, and education status, the odds of females, Spanish-speaking, students, and disabled patients missing their appointment were no longer statistically significant.

CONCLUSION

A majority of patients at BMC come from lower SES backgrounds and have multiple medical comorbidities. Those who reside closer to BMC, often areas of lower average income, had higher rates of missed appointments. Interventions such as decreasing lag time, providing handicap-accessible free transportation, and increasing accessibility of telemedicine for patients could help improve attendance rates at BMC.

LEVEL OF EVIDENCE

IV Laryngoscope, 134:4003-4010, 2024.

Assessing the Association of Healthcare Resource Utilization and Patient-Reported Outcomes on Shared Decision-Making among Multimorbid Individuals

Shared decision-making (SDM) is an essential component of patient-centered healthcare and disease management. However, the association of SDM with healthcare resource utilization and patient-reported outcomes among multimorbid individuals is not well understood. This study sought to evaluate the association of SDM with healthcare resource utilization and patient-reported outcomes among United States (US) adults with multimorbidity. Data were collected from the 2020 Medical Expenditure Panel Survey (MEPS) for this cross-sectional study. Eligible participants were US adults with two or more comorbidities. The predictor variable was SDM (optimal versus not optimal). The outcome variables were healthcare resource utilization and patient-reported outcomes. Logistic regression models, adjusted for demographic characteristics, assessed associations with SDM for each healthcare resource utilization and patient-reported outcome variable. The analysis maintained the complex survey data and was weighted to produce nationally representative estimates. Individuals who reported optimal SDM in adjusted analyses utilized more healthcare resources compared to those who reported not optimal SDM. Individuals with optimal SDM had more than one outpatient visit (odds ratio OR = 1.23, 95% CI = 1.03-1.47), emergency room visit (OR = 1.55, 95% CI = 1.17-2.06), and inpatient discharge (OR = 1.44, 95% CI = 1.05-1.96). Additionally, these individuals had higher odds of reporting limitations in their ability to work or engage in other activities due to their physical health in the past four weeks (OR = 1.27, 95% CI = 1.01-1.60). This study indicated evidence of increased healthcare resource utilization among patients who participate in SDM with their providers, which should be explored in future studies.

Challenges in managing HIV and non-communicable diseases and health workers' perception regarding integrated management of non-communicable diseases during routine HIV care in South Central Uganda: A qualitative study

BACKGROUND

Non-communicable diseases are highly prevalent among adults living with HIV, emphasizing the need for comprehensive healthcare strategies. However, a dearth of knowledge exists regarding the health systems challenges in managing HIV and non-communicable diseases and the perception of health workers regarding the integrated management of non-communicable diseases during routine HIV care in rural Ugandan settings. This study aims to bridge this knowledge gap by exploring the health system challenges in managing HIV and non-communicable diseases and health workers' perception regarding the integration of non-communicable diseases in routine HIV care in South Central Uganda.

METHODS

In this qualitative study, we collected data from 20 purposively selected key informants from Kalisizo Hospital and Rakai Hospital in South Central Uganda. Data were collected from 15th December 2020 and 14th January 2021. Data were analyzed using a thematic content approach with the help of NVivo 11.

RESULTS

Of the 20 health workers, 13 were females. In terms of work duration, 9 had worked with people living with HIV for 11-15 years and 9 were nurses. The challenges in managing HIV and non-communicable diseases included difficulty managing adverse events, heavy workload, inadequate communication from specialists to lower cadre health workers, limited financial and human resources, unsupportive clinical guidelines that do not incorporate non-communicable disease management in HIV care and treatment, and inadequate knowledge and skills required to manage non-communicable diseases appropriately. Health workers suggested integrating non-communicable disease management into routine HIV care and suggested the need for training before this integration.

CONCLUSION

The integration of non-communicable disease management into routine HIV care presents a promising avenue for easing the burden on health workers handling these conditions. However, achieving successful integration requires not only the training of health workers but also ensuring the availability of sufficient human and financial resources.

Core outcome sets for trials of interventions to prevent and to treat multimorbidity in adults in low and middle-income countries: the COSMOS study

INTRODUCTION

The burden of multimorbidity is recognised increasingly in low- and middle-income countries (LMICs), creating a strong emphasis on the need for effective evidence-based interventions. Core outcome sets (COS) appropriate for the study of multimorbidity in LMICs do not presently exist. These are required to standardise reporting and contribute to a consistent and cohesive evidence-base to inform policy and practice. We describe the development of two COS for intervention trials aimed at preventing and treating multimorbidity in adults in LMICs.

METHODS

To generate a comprehensive list of relevant prevention and treatment outcomes, we conducted a systematic review and qualitative interviews with people with multimorbidity and their caregivers living in LMICs. We then used a modified two-round Delphi process to identify outcomes most important to four stakeholder groups (people with multimorbidity/caregivers, multimorbidity researchers, healthcare professionals and policymakers) with representation from 33 countries. Consensus meetings were used to reach agreement on the two final COS.

REGISTRATION

https://www.comet-initiative.org/Studies/Details/1580.

RESULTS

The systematic review and qualitative interviews identified 24 outcomes for prevention and 49 for treatment of multimorbidity. An additional 12 prevention and 6 treatment outcomes were added from Delphi round 1. Delphi round 2 surveys were completed by 95 of 132 round 1 participants (72.0%) for prevention and 95 of 133 (71.4%) participants for treatment outcomes. Consensus meetings agreed four outcomes for the prevention COS: (1) adverse events, (2) development of new comorbidity, (3) health risk behaviour and (4) quality of life; and four for the treatment COS: (1) adherence to treatment, (2) adverse events, (3) out-of-pocket expenditure and (4) quality of life.

CONCLUSION

Following established guidelines, we developed two COS for trials of interventions for multimorbidity prevention and treatment, specific to adults in LMIC contexts. We recommend their inclusion in future trials to meaningfully advance the field of multimorbidity research in LMICs.

PROSPERO REGISTRATION NUMBER

CRD42020197293.

Effectiveness and cost-effectiveness of offering a chair-based yoga programme in addition to usual care in older adults with multiple long-term conditions: a pragmatic, parallel group, open label, randomised controlled trial

Background

People with multiple long-term conditions are more likely to have poorer health-related quality of life (HRQOL). Yoga has the potential to improve HRQOL. Gentle Years Yoga© (GYY) is a chair-based yoga programme for older adults. We investigated the effectiveness and cost-effectiveness of the GYY programme in older adults with multiple long-term conditions.

Methods

In this pragmatic, multi-site, open, randomised controlled trial, we recruited adults aged ≥65 years with ≥2 long-term conditions from 15 primary care practices in England and Wales. Participants were randomly assigned to usual care control or a 12-week, group-based, GYY programme delivered face-to-face or online by qualified yoga teachers. The primary outcome was HRQOL (EQ-5D-5L) over 12 months. Secondary outcomes included anxiety, depression, falls, loneliness, healthcare resource use, and adverse events.

Results

Between October 2019 and October 2021, 454 participants were randomised between the intervention (n=240) and control (n=214) groups. Seven GYY courses were delivered face-to-face and 12 courses were delivered online. The mean number of classes attended among all intervention participants was nine (SD 4, median 10). In our intention-to-treat analysis (n=422), there was no statistically significant difference between trial groups in the primary outcome of HRQOL (adjusted difference in mean EQ-5D-5L = 0.020 [favouring intervention]; 95% CI -0.006 to 0.045, p=0.14). There were also no statistically significant differences in key secondary outcomes. No serious, related adverse events were reported. The incremental cost-effectiveness ratio was £4,546 per quality-adjusted life-year (QALY) and the intervention had a 79% probability of being cost-effective at a willingness-to-pay threshold of £20,000 per QALY. The intervention was acceptable to most participants and perceived as useful by some.

Conclusions

The offer of a 12-week chair-based yoga programme in addition to usual care did not improve HRQOL in older adults with multiple long-term conditions. However, the intervention was safe, acceptable, and probably cost-effective.

Changes in patterns of multimorbidity and associated with medical costs among Chinese middle-aged and older adults from 2013 to 2023: an analysis of repeated cross-sectional surveys in Xiangyang, China

Background

Multimorbidity has become a major public health problem among Chinese middle-aged and older adults, and the most costly to the health care system. However, most previous population-based studies of multimorbidity have focused on a limited number of chronic diseases, and diagnosis was based on participants' self-report, which may oversimplify the problem. At the same time, there were few reports on the relationship between multimorbidity patterns and health care costs. This study analyzed the multimorbidity patterns and changes among middle-aged and older people in China over the past decade, and their association with medical costs, based on representative hospital electronic medical record data.

Methods

Two cross-sectional surveys based on representative hospital data were used to obtain adults aged 45 years and older in Xiangyang in 2013 (n = 20,218) and 2023 (n = 63,517). Latent Class Analysis was used to analyze changes in the patterns of multimorbidity, gray correlation analysis and ordered logistics model were used to assess the association of multimorbidity patterns with medical expenses. The diagnosis and classification of chronic diseases were based on the International Classification of Diseases, Tenth Revision codes (ICD-10).

Results

The detection rate of chronic disease multimorbidity has increased (70.74 vs. 76.63%, p < 0.001), and multimorbidity patterns have increased from 6 to 9 (2013: Malignant tumors pattern, non-specific multimorbidity pattern, ischemic heart disease + hypertension pattern, cerebral infarction + hypertension pattern, kidney disease + hypertension pattern, lens disease + hypertension pattern; new in 2023: Nutritional metabolism disorders + hypertension pattern, chronic lower respiratory diseases + malignant tumors pattern, and gastrointestinal diseases pattern) in China. The medical cost of all multimorbidity patients have been reduced between 2013 and 2023 (RMB: 8216.74 vs. 7247.96, IQR: 5802.28-15,737 vs. 5014.63-15434.06). The top three specific multimorbidity patterns in both surveys were malignancy tumor pattern, ischemic heart disease + hypertension pattern, and cerebral infarction + hypertension pattern. Hypertension and type 2 diabetes are important components of multimorbidity patterns. Compared with patients with a single disease, only lens disorders + hypertension pattern were at risk of higher medical costs in 2013 (aOR:1.23, 95% CI: 1.03, 1.47), whereas all multimorbidity patterns were significantly associated with increased medical costs in 2023, except for lens disorders + hypertension (aOR:0.35, 95% CI: 0.32, 0.39). Moreover, the odds of higher medical costs were not consistent across multimorbidity patterns. Among them, ischemic heart disease + hypertension pattern [adjusted odds ratio (aOR):4.66, 95%CI: 4.31, 5.05] and cerebral infarction + hypertension pattern (aOR: 3.63, 95% CI: 3.35, 3.92) were the two patterns with the highest risk. Meanwhile, men (aOR:1.12, 95CI:1.09, 1.16), no spouse (aOR:1.09, 95CI: 1.03, 1.16) had a positive effect on medical costs, while patients with total self-pay (aOR: 0.45, 95CI: 0.29, 0.70), no surgery (aOR: 0.05, 95CI: 0.05, 0.05), rural residence (aOR: 0.92, 95CI: 0.89, 0.95), hospitalization days 1-5 (aOR: 0.04, 95CI: 0.04, 0.04), and hospitalization days 6-9 (aOR: 0.15, 95CI: 0.15, 0.16) had a negative impact on medical costs.

Conclusion

Multimorbidity patterns among middle-aged and older adults in China have diversified over the past decade and are associated with rising health care costs in China. Smart, decisive and comprehensive policy and care interventions are needed to effectively manage NCDS and their risk factors and to reduce the economic burden of multimorbidity on patients and the country.

Epidemiology and Treatment of Patients With Primary Open Angle Glaucoma in Germany: A Health Claims Data Analysis

PRCIS

Based on a large administrative database of German claims data, our study provides current estimates of the prevalence and incidence of primary open angle glaucoma (POAG) in Germany and describes selected outcomes for prevalent patients with POAG.

PURPOSE

To estimate the prevalence and incidence of POAG in Germany, to describe the patient population in terms of comorbidity burden, routine care, and overall healthcare resource utilization (HCRU) and associated costs, and to describe treatment patterns over time in patients undergoing relevant laser procedures.

MATERIALS AND METHODS

Based on anonymized German claims data, we carried out a retrospective, noninterventional study covering calendar years 2016-2021.

RESULTS

For the adult German population (≥18 y), we estimated a POAG 1-year prevalence of 1.70% and a 1-year incidence of 0.17% in 2018; both increased with age, peaking in 80- to 89-year-olds. Prevalence and incidence were lower in 2020 (1.65% and 0.16%, respectively), the first year of the SARS-CoV-2 pandemic. Most patients solely received topical treatment. Most surgically treated patients underwent laser trabeculoplasty, followed by laser iridotomy, trabeculectomy, and filtration operations with implant. In patients undergoing laser trabeculoplasty, the treatment regimen was nearly unchanged in the second year after, compared with 2 years before the procedure. Multimorbidity was commonly observed; 75.5% of patients had arterial hypertension and 50.0% had disorders of lipoprotein metabolism and other lipidemias, compared with 60.1% and 39.2%, respectively, in an age- and sex-matched control sample.

CONCLUSIONS

Our study provides insights into epidemiology and routine care of POAG in Germany and HCRU in prevalent patients. There was little change in treatment regimens in patients who underwent laser trabeculoplasty, 2 years after the procedure. Most patients were multimorbid highlighting the need for comprehensive care.

Dysregulated bile acid homeostasis: unveiling its role in metabolic diseases

Maintaining bile acid homeostasis is essential for metabolic health. Bile acid homeostasis encompasses a complex interplay between biosynthesis, conjugation, secretion, and reabsorption. Beyond their vital role in digestion and absorption of lipid-soluble nutrients, bile acids are pivotal in systemic metabolic regulation. Recent studies have linked bile acid dysregulation to the pathogenesis of metabolic diseases, including obesity, type 2 diabetes mellitus (T2DM), and metabolic dysfunction-associated steatotic liver disease (MASLD). Bile acids are essential signaling molecules that regulate many critical biological processes, including lipid metabolism, energy expenditure, insulin sensitivity, and glucose metabolism. Disruption in bile acid homeostasis contributes to metabolic disease via altered bile acid feedback mechanisms, hormonal dysregulation, interactions with the gut microbiota, and changes in the expression and function of bile acid transporters and receptors. This review summarized the essential molecular pathways and regulatory mechanisms through which bile acid dysregulation contributes to the pathogenesis and progression of obesity, T2DM, and MASLD. We aim to underscore the significance of bile acids as potential diagnostic markers and therapeutic agents in the context of metabolic diseases, providing insights into their application in translational medicine.

Multimorbidity and associated informal care receiving characteristics for US older adults: a latent class analysis

BACKGROUND

Older adults with varying patterns of multimorbidity may require distinct types of care and rely on informal caregiving to meet their care needs. This study aims to identify groups of older adults with distinct, empirically-determined multimorbidity patterns and compare characteristics of informal care received among estimated classes.

METHODS

Data are from the 2011 National Health and Aging Trends Study (NHATS). Ten chronic conditions were included to estimate multimorbidity patterns among 7532 individuals using latent class analysis. Multinomial logistic regression model was estimated to examine the association between sociodemographic characteristics, health status and lifestyle variables, care-receiving characteristics and latent class membership.

RESULTS

A four-class solution identified the following multimorbidity groups: some somatic conditions with moderate cognitive impairment (30%), cardiometabolic (25%), musculoskeletal (24%), and multisystem (21%). Compared with those who reported receiving no help, care recipients who received help with household activities only (OR = 1.44, 95% CI 1.05-1.98), mobility but not self-care (OR = 1.63, 95% CI 1.05-2.53), or self-care but not mobility (OR = 2.07, 95% CI 1.29-3.31) had greater likelihood of being in the multisystem group versus the some-somatic group. Having more caregivers was associated with higher odds of being in the multisystem group compared with the some-somatic group (OR = 1.09, 95% CI 1.00-1.18), whereas receiving help from paid helpers was associated with lower odds of being in the multisystem group (OR = 0.36, 95% CI 0.19-0.77).

CONCLUSIONS

Results highlighted different care needs among persons with distinct combinations of multimorbidity, in particular the wide range of informal needs among older adults with multisystem multimorbidity. Policies and interventions should recognize the differential care needs associated with multimorbidity patterns to better provide person-centered care.

Cost of Care for Non-communicable Diseases: Which Types of Healthcare Providers are the Most Economical in India's Chhattisgarh State?

BACKGROUND

Non-communicable diseases (NCDs) affect a large number of people globally and their burden has been growing. Healthcare for NCDs often involves high out-of-pocket expenditure and rising costs of providing services. Financing and providing care for NCDs have become a major challenge for health systems. Despite the high burden of NCDs in India, there is little information available on the costs involved in NCD care.

METHODS

The study was aimed at finding out the average monthly cost of outpatient care per NCD patient. The average cost was defined as all resources spent directly by government and citizens to get a month of care for a NCD patient. The cost borne by the government on public facilities was taken into account and activity-based costing was used to apportion it to the function of providing outpatient NCD care. For robustness, time-driven activity-based costing and sensitivity analyses were also performed. The study was conducted in Chhattisgarh State and involved a household survey and a facility survey, conducted simultaneously at the end of 2022. The surveys had a sample representative of the state, covering 3500 individuals above age of 30 years and 108 health facilities.

RESULTS

The average monthly cost per NCD patient was Indian Rupees (INR) 688 for public providers, INR 1389 for formal for-profit providers and INR 408 for informal private providers and they managed 53.5, 34.3 and 12.0% of NCD patients respectively. The disease profile of patients handled by different types of providers was similar. The average cost per patient was lowest for the primary care facilities in the public sector.

CONCLUSIONS

The average direct cost of NCD care for government and citizens put together was substantially higher in case of formal for-profit providers compared with public facilities, even after taking into account the government subsidies to public sector. This has implications for allocative efficiency and the desired public-private provider mix in health systems.

Predictive analytics support for complex chronic medical conditions: An experience-based co-design study of physician managers' needs and preferences

PURPOSE

The literature suggests predictive technology applications in health care would benefit from physician and manager input during design and development. The aim was to explore the needs and preferences of physician managers regarding the role of predictive analytics in decision support for patients with the highly complex yet common combination of multiple chronic conditions of cardiovascular (Heart) and kidney (Nephrology) diseases and diabetes (HND).

METHODS

This qualitative study employed an experience-based co-design model comprised of three data gathering phases: 1. Patient mapping through non-participant observations informed by process mining of electronic health records data, 2. Semi-structured experience-based interviews, and 3. A co-design workshop. Data collection was conducted with physician managers working at or collaborating with the HND center, Danderyd University Hospital (DSAB), in Stockholm, Sweden. HND center is an integrated practice unit offering comprehensive person-centered multidisciplinary care to stabilize disease progression, reduce visits, and develop treatment strategies that enables a transition to primary care.

RESULTS

Interview and workshop data described a complex challenge due to the interaction of underlying pathophysiologies and the subsequent need for multiple care givers that hindered care continuity. The HND center partly met this challenge by coordinating care through multiple interprofessional and interdisciplinary shared decision-making interfaces. The large patient datasets were difficult to operationalize in daily practice due to data entry and retrieval issues. Predictive analytics was seen as a potentially effective approach to support decision-making, calculate risks, and improve resource utilization, especially in the context of complex chronic care, and the HND center a good place for pilot testing and development. Simplicity of visual interfaces, a better understanding of the algorithms by the health care professionals, and the need to address professional concerns, were identified as key factors to increase adoption and facilitate implementation.

CONCLUSIONS

The HND center serves as a comprehensive integrated practice unit that integrates different medical disciplinary perspectives in a person-centered care process to address the needs of patients with multiple complex comorbidities. Therefore, piloting predictive technologies at the same time with a high potential for improving care represents an extreme, demanding, and complex case. The study findings show that health care professionals' involvement in the design of predictive technologies right from the outset can facilitate the implementation and adoption of such technologies, as well as enhance their predictive effectiveness and performance. Simplicity in the design of predictive technologies and better understanding of the concept and interpretation of the algorithms may result in implementation of predictive technologies in health care. Institutional efforts are needed to enhance collaboration among the health care professionals and IT professionals for effective development, implementation, and adoption of predictive analytics in health care.

Individual- and Community-Level Predictors of Hospital-at-Home Outcomes

Advanced Care at Home is a Mayo Clinic hospital-at-home (HaH) program that provides hospital-level care for patients. The study examines patient- and community-level factors that influence health outcomes. The authors performed a retrospective study using patient data from July 2020 to December 2022. The study includes 3 Mayo Clinic centers and community-level data from the Agency for Healthcare Research and Quality. The authors conducted binary logistic regression analyses to examine the relationship among the independent variables (patient- and community-level characteristics) and dependent variables (30-day readmission, mortality, and escalation of care back to the brick-and-mortar hospital). The study examined 1433 patients; 53% were men, 90.58% were White, and 68.2% were married. The mortality rate was 2.8%, 30-day readmission was 11.4%, and escalation back to brick-and-mortar hospitals was 8.7%. At the patient level, older age and male gender were significant predictors of 30-day mortality (P-value <0.05), older age was a significant predictor of 30-day readmission (P-value <0.05), and severity of illness was a significant predictor for readmission, mortality, and escalation back to the brick-and-mortar hospital (P-value <0.01). Patients with COVID-19 were less likely to experience readmission, mortality, or escalations (P-value <0.05). At the community level, the Gini Index and internet access were significant predictors of mortality (P-value <0.05). Race and ethnicity did not significantly predict adverse outcomes (P-value >0.05). This study showed promise in equitable treatment of diverse patient populations. The authors discuss and address health equity issues to approximate the vision of inclusive HaH delivery.

Medical expenses and its determinants in female patients with urological disorder

BACKGROUND

The rising older adult population has led to an increase in the prevalence of chronic diseases and medical expenses. Women tend to have a longer healthy life expectancy than men and are more likely to be exposed to urological disorders around the age of 50, resulting in substantial healthcare expenses throughout their lifetime. Urological disorders often require continuous treatment owing to their high risk of recurrence, contributing to an increased financial burden from medical costs. This study aimed to identify factors influencing medical expense in female patients with urological disorders and propose strategies to alleviate the associated financial burden.

METHODS

We used data from the Korea Health Panel Survey conducted from 2011 to 2016. The final sample comprised 2,932 patients who visited hospitals for urological disorders. To identify the factors influencing medical expense among female patients with urological disorders, we employed a generalized estimating equation model.

RESULTS

The results indicated that younger people and patients with middle-income levels tended to incur higher medical expenses. Furthermore, patients receiving treatment at tertiary hospitals and those enrolled in National Health Insurance also incurred higher health expenses.

CONCLUSIONS

This study suggests that effective management of medical expenses related to urological disorders in women requires improvements in healthcare accessibility to facilitate early detection and continuous disease management. In addition, the findings highlight the potential benefits of digital health and non-face-to-face treatments in addressing these needs.

Progressive Supranuclear palsy (PSP) disease progression, management, and healthcare resource utilization: a retrospective observational study in the US and Canada

BACKGROUND

Progressive supranuclear palsy (PSP) is a rare neurodegenerative brain disease with rapid progression and currently limited treatment options. A comprehensive understanding of disease progression, management, and healthcare resource utilization is limited, and further research is challenging due to the small population of patients. To address these challenges in conducting PSP research, individuals with PSP were recruited using a multichannel approach tailored specifically to the PSP community. We performed a retrospective observational study using data abstracted from participant medical records collected from multiple patient care centers.

RESULTS

Seventy-two individuals with PSP were eligible for inclusion. On average, 144 medical documents per participant were collected from an average of 2.9 healthcare centers per participant, with a mean study period of 7.9 years. Among participants with a date of symptom onset documented in the medical records, the median time for the onset of the first fall was 2.0 years (IQR 3.2) before diagnosis, the median onset of unsteady gait or gait impairment was 1.2 years (IQR 1.8) before diagnosis, and the median onset of mobility problems was 0.8 years (IQR 1.8) before diagnosis. The most widely utilized healthcare resources, with at least 85% of participants using each of these resources at some point during the disease course, were medications (100%), imaging (99%), assistive devices (90%), supportive care (86%), and surgeries and procedures (85%).

CONCLUSIONS

This retrospective study adds to the current understanding of PSP symptoms, comorbidities, and healthcare resource utilization (HRU) across the disease journey. By involving individuals with PSP and their caregivers or legally authorized representatives in the research process, this study was unique in its approach to participant recruitment and enabled individuals to participate in research without the need for travel. We collected medical documents from multiple healthcare centers, allowing for broad data collection covering the entire disease journey. This approach to the collection of real-world data may be used to generate valuable insights into many aspects of disease progression and management in PSP and many other rare diseases.

Multimorbidity patterns and trajectories in young and middle-aged adults: a large-scale population-based cohort study

Introduction

The presence of multiple chronic conditions, also referred to as multimorbidity, is a common finding in adults. Epidemiologic research can help identify groups of individuals with similar clinical profiles who could benefit from similar interventions. Many cross-sectional studies have revealed the existence of different multimorbidity patterns. Most of these studies were focused on the older population. However, multimorbidity patterns begin to form at a young age and can evolve over time following distinct multimorbidity trajectories with different impact on health. In this study, we aimed to identify multimorbidity patterns and trajectories in adults 18-65 years old.

Methods

We conducted a retrospective longitudinal epidemiologic study in the EpiChron Cohort, which includes all inhabitants of Aragón (Spain) registered as users of the Spanish National Health System, linking, at the patient level, information from electronic health records from both primary and specialised care. We included all 293,923 patients 18-65 years old with multimorbidity in 2011. We used cluster analysis at baseline (2011) and in 2015 and 2019 to identify multimorbidity patterns at four and eight years of follow-up, and we then created alluvial plots to visualise multimorbidity trajectories. We performed age- and sex-adjusted logistic regression analysis to study the association of each pattern with four- and eight-year mortality.

Results

We identified three multimorbidity patterns at baseline, named dyslipidaemia & endocrine-metabolic, hypertension & obesity, and unspecific. The hypertension & obesity pattern, found in one out of every four patients was associated with a higher likelihood of four- and eight-year mortality (age- and sex-adjusted odds ratio 1.11 and 1.16, respectively) compared to the unspecific pattern. Baseline patterns evolved into different patterns during the follow-up.

Discussion

Well-known preventable cardiovascular risk factors were key elements in most patterns, highlighting the role of hypertension and obesity as risk factors for higher mortality. Two out of every three patients had a cardiovascular profile with chronic conditions like diabetes and obesity that are linked to low-grade systemic chronic inflammation. More studies are encouraged to better characterise the relatively large portion of the population with an unspecific disease pattern and to help design and implement effective and comprehensive strategies towards healthier ageing.

Eye Movement Desensitization and Reprocessing (EMDR) treatment in the medical setting: a systematic review

Background: Literature points towards the potential benefits of the application of Eye Movement and Desensitization Processing (EMDR)-therapy for patients in the medical setting, with cancer and pain being among the domains it is applied to. The field of applying EMDR-therapy for patients treated in the medical setting has evolved to such an extent that it may be challenging to get a comprehensive overview.Objective: This systematic literature review aims to evaluate the use and effectiveness of Eye Movement Desensitization and Reprocessing (EMDR) therapy in patients treated in the medical setting.Methods: We performed a literature search following the PRISMA guidelines. Studies were included if the effectiveness of EMDR-therapy was assessed in adult patients treated in a medical setting. Excluded were patients exclusively suffering from a mental health disorder, without somatic comorbidity. A risk of bias analysis was performed. This review was registered on PROSPERO (CRD42022325238).Results: Eighty-seven studies, of which 26 (pilot)-RCTs were included and categorized in 14 medical domains. Additionally, three studies focusing on persistent physical complaints were included. Most evidence exists for its application in the fields of oncology, pain, and neurology. The overall appraisal of these studies showed at least moderate to high risks of bias. EMDR demonstrated effectiveness in reducing symptoms in 85 out of 87 studies. Notably, the occurrence of adverse events was rarely mentioned.Conclusions: Overall, outcomes seem to show beneficial effects of EMDR on reducing psychological and physical symptoms in patients treated in a medical setting. Due to the heterogeneity of reported outcomes, effect sizes could not be pooled. Due to the high risk of bias of the included studies, our results should be interpreted with caution and further controlled high-quality research is needed.

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.

Multimorbidity patterns and health-related quality of life among community-dwelling older adults: evidence from a rural town in Suzhou, China

PURPOSE

The high prevalence of multimorbidity in aging societies has posed tremendous challenges to the healthcare system. The aim of our study was to comprehensively assess the association of multimorbidity patterns and health-related quality of life (HRQOL) among rural Chinese older adults.

METHODS

This was a cross-sectional study. Data from 4,579 community-dwelling older adults aged 60 years and above was collected by the clinical examination and questionnaire survey. Information on 10 chronic conditions was collected and the 3-Level EQ-5D (EQ-5D-3L) was adopted to measure the HRQOL of older adults. An exploratory factor analysis was performed to determine multimorbidity patterns. Regression models were fitted to explore the associations of multimorbidity patterns with specific health dimensions and overall HRQOL.

RESULTS

A total of 2,503 (54.7%) participants suffered from multimorbidity, and they reported lower HRQOL compared to those without multimorbidity. Three kinds of multimorbidity patterns were identified including cardiovascular-metabolic diseases, psycho-cognitive diseases and organic diseases. The associations between psycho-cognitive diseases/organic diseases and overall HRQOL assessed by EQ-5D-3L index score were found to be significant (β = - 0.097, 95% CI - 0.110, - 0.084; β = - 0.030, 95% CI - 0.038, - 0.021, respectively), and psycho-cognitive diseases affected more health dimensions. The impact of cardiovascular-metabolic diseases on HRQOL was largely non-significant.

CONCLUSION

Multimorbidity was negatively associated with HRQOL among older adults from rural China. The presence of the psycho-cognitive diseases pattern or the organic diseases pattern contributed to worse HRQOL. The remarkable negative impact of psycho-cognitive diseases on HRQOL necessiates more attention and relevant medical assistance to older rural adults.

Multimorbidity in middle-aged women and COVID-19: binary data clustering for unsupervised binning of rare multimorbidity features and predictive modeling

BACKGROUND

Multimorbidity is typically associated with deficient health-related quality of life in mid-life, and the likelihood of developing multimorbidity in women is elevated. We address the issue of data sparsity in non-prevalent features by clustering the binary data of various rare medical conditions in a cohort of middle-aged women. This study aims to enhance understanding of how multimorbidity affects COVID-19 severity by clustering rare medical conditions and combining them with prevalent features for predictive modeling. The insights gained can guide the development of targeted interventions and improved management strategies for individuals with multiple health conditions.

METHODS

The study focuses on a cohort of 4477 female patients, (aged 45-60) in Piedmont, Italy, and utilizes their multimorbidity data prior to the COVID-19 pandemic from their medical history from 2015 to 2019. The COVID-19 severity is determined by the hospitalization status of the patients from February to May 2020. Each patient profile in the dataset is depicted as a binary vector, where each feature denotes the presence or absence of a specific multimorbidity condition. By clustering the sparse medical data, newly engineered features are generated as a bin of features, and they are combined with the prevalent features for COVID-19 severity predictive modeling.

RESULTS

From sparse data consisting of 174 input features, we have created a low-dimensional feature matrix of 17 features. Machine Learning algorithms are applied to the reduced sparsity-free data to predict the Covid-19 hospital admission outcome. The performance obtained for the corresponding models are as follows: Logistic Regression (accuracy 0.72, AUC 0.77, F1-score 0.69), Linear Discriminant Analysis (accuracy 0.7, AUC 0.77, F1-score 0.67), and Ada Boost (accuracy 0.7, AUC 0.77, F1-score 0.68).

CONCLUSION

Mapping higher-dimensional data to a low-dimensional space can result in information loss, but reducing sparsity can be beneficial for Machine Learning modeling due to improved predictive ability. In this study, we addressed the issue of data sparsity in electronic health records and created a model that incorporates both prevalent and rare medical conditions, leading to more accurate and effective predictive modeling. The identification of complex associations between multimorbidity and the severity of COVID-19 highlights potential areas of focus for future research, including long COVID and intervention efforts.