The dimensions of multiple chronic conditions: where do we go from here? A commentary on the Special Issue of Preventing Chronic Disease

Convergence of four measures of multi-morbidity

Objectives

To compare the agreement between percentile ranks from 4 multi-morbidity scores.

Design

Population-based descriptive study.

Setting

Olmsted County, Minnesota (USA).

Participants

We used the medical records-linkage system of the Rochester Epidemiology Project (REP; http://www.rochesterproject.org) to identify all residents of Olmsted County, Minnesota who reached one or more birthdays between 1 January 2005 and 31 December 2014 (10 years).

Methods

For each person, we calculated 4 multi-morbidity scores using readily available diagnostic code lists from the US Department of Health and Human Services, the Clinical Classifications Software, and the Elixhauser Comorbidity Index. We calculated scores using diagnostic codes received in the 5 years before the index birthday and fit quantile regression models across age and separately by sex to transform unweighted, simple counts of conditions into percentile ranks as compared to peers of same age and of same sex. We compared the percentile ranks of the 4 multi-morbidity scores using intra-class correlation coefficients (ICCs).

Results

We assessed agreement in 181,553 persons who reached a total of 1,075,433 birthdays at ages 18 years through 85 years during the study period. In general, the percentile ranks of the 4 multi-morbidity scores exhibited high levels of agreement in 6 score-to-score pairwise comparisons. The agreement increased with older age for all pairwise comparisons, and ICCs were consistently greater than 0.65 at ages 50 years and older.

Conclusions

The assignment of percentile ranks may be a simple and intuitive way to assess the underlying trait of multi-morbidity across studies that use different measures.

Associations of Multiple Chronic Conditions With Physical Performance and Falls Among Older Adults With Back Pain: A Longitudinal, Population-based Study

OBJECTIVE

To determine the association of chronic conditions measured at baseline with physical performance and falls over time among older adults with back pain. We examined both number and type (depression, anxiety, arthritis) of chronic conditions.

DESIGN

Retrospective cohort study.

SETTING

National Health and Aging Trends Study.

PARTICIPANTS

A total of 2438 community-dwelling Medicare beneficiaries aged ≥65 years with bothersome back pain (N=2438). The sample was mostly female (62%; 95% confidence interval [CI], 59%-64%) and aged 65-74 years (56%; 95% CI, 53%-58%).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Short Physical Performance Battery (SPPB) (range, 0-12, lower indicates worse function) and recurrent falls measured annually over 6 years.

RESULTS

Multiple chronic conditions were highly prevalent (82%; 95% CI, 79%-84%) among those reporting back pain. Adjusted regressions using survey weights with Taylor series linearization method and containing interaction terms for comorbidity and time showed having 2-3 chronic conditions vs 0-1 was associated with lower SPPB scores, and differences grew over time (for example 0.61 points lower [95% CI, -0.88 to -0.34] and 1.22 points lower [95% CI, -1.76 to -0.67] in rounds 3 and 6, respectively). Having ≥4 chronic conditions was associated with lower SPPB scores at all time points vs 0-1 (point estimate range, -1.72 to -2.31). Arthritis alone; the combination of arthritis with depression; and the triad of arthritis, depression, and anxiety were associated with lower SPPB scores at all time points. Logistic regression models showed presence of 2-3 and ≥4 chronic conditions was associated with increased odds of recurrent falls in any given year (odds ratio, 1.91; 95% CI, 1.35-2.69 and odds ratio, 3.92; 95% CI, 2.81-5.46, respectively). Those with the triad of arthritis, depression, and anxiety had greater odds of recurrent falls vs none or 1 condition.

CONCLUSIONS

Among older adults with back pain, those with multiple chronic conditions, including co-occurrence of arthritis, depression, and anxiety, have greater risk for poor physical functioning and falls over time.

Multimorbidity, ageing and mortality: normative data and cohort study in an American population

OBJECTIVES

To describe the percentile distribution of multimorbidity across age by sex, race and ethnicity, and to demonstrate the utility of multimorbidity percentiles to predict mortality.

DESIGN

Population-based descriptive study and cohort study.

SETTING

Olmsted County, Minnesota (USA).

PARTICIPANTS

We used the medical records-linkage system of the Rochester Epidemiology Project (REP; http://www.rochesterproject.org) to identify all residents of Olmsted County, Minnesota who reached one or more birthdays between 1 January 2005 and 31 December 2014 (10 years).

METHODS

For each person, we obtained the count of chronic conditions (out of 20 conditions) present on each birthday by extracting all of the diagnostic codes received in the 5 years before the index birthday from the electronic indexes of the REP. To compare each person's count to peers of same age, the counts were transformed into percentiles of the total population and displayed graphically across age by sex, race and ethnicity. In addition, quintiles 1, 2, 4 and 5 were compared with quintile 3 (reference) to predict the risk of death at 1 year, 5 years and through end of follow-up using time-to-event analyses. Follow-up was passive using the REP.

RESULTS

We identified 238 010 persons who experienced a total of 1 458 094 birthdays during the study period (median of 6 birthdays per person; IQR 3-10). The percentiles of multimorbidity across age did not vary noticeably by sex, race or ethnicity. In general, there was an increased risk of mortality at 1 and 5 years for quintiles 4 and 5 of multimorbidity. The risk of mortality for quintile 5 was greater for younger age groups and for women.

CONCLUSIONS

The assignment of multimorbidity percentiles to persons in a population may be a simple and intuitive tool to assess relative health status, and to predict short-term mortality, especially in younger persons and in women.

An integrated model of multimorbidity and symptom science

BACKGROUND

Prevalence and complexity of persons with multiple chronic conditions (MCC), also known as multimorbidity, are shifting clinical practice from a single disease focus to one considering MCC and symptoms. Although symptoms are intricately bound to concepts inherent in MCC science, symptoms are largely ignored in multimorbidity research and literature.

PURPOSE

Introduce an Integrated Model of Multimorbidity and Symptom Science.

METHODS

Critical integrative review and synthesis process.

FINDINGS

The model comprises three primary domains: 1. Contributing/ Risk Factors; 2. Symptom/Disease/Treatment Interactions; and 3. Patient Outcomes.

DISCUSSION

The model highlights the multilevel nature of contributing factors and the recursive interactions among multiple etiologies, conditions, symptoms, therapies, and outcomes.

Toward total student health: A qualitative pilot study

Objective: Colleges should aim to cultivate healthy behaviors among students by addressing alterations in wellness students view as important. The purpose of this study was to determine the self-perceived wellness-related concerns and behaviors of college students. Participants: Thirty-seven undergraduate students participated in this study between January and March 2017. Methods: Focus groups served as a data collection method. Groups were recorded and transcribed verbatim. Directed and conventional approaches to data analyses were employed. Results: Participants expressed concern regarding four campus wellness topics: nutrition, economics, mental health, and campus safety. Participants offered solutions for improving campus wellness, representing a fifth theme. Conclusions: Health concerns for college students and realistic solutions to address concerns were identified across focus groups. Overall, students cared about their own health, as well as the well-being of other students. Future directions include conducting a Web-based survey among students to assess prevalence and impact of select health and wellness topics.

An Examination of Demographic and Psychosocial Factors, Barriers to Healthy Eating, and Diet Quality Among African American Adults

A healthy diet is associated with lower risk of chronic disease. African Americans generally have poor diet quality and experience a higher burden of many chronic diseases. We examined the associations of demographic and psychosocial factors and barriers to diet quality among African American adults. This cross-sectional study included 100 African American adults in a southeastern metropolitan area. Psychosocial factors (social support, self-efficacy), and barriers to healthy eating were assessed with validated measures. Diet quality was assessed using the Healthy Eating Index (HEI-2010). Nested linear regressions were used to examine the association between the variables of interest and HEI scores. Participants reported having social support (M (mean) = 2.0, SD (standard deviation) = 0.6, range 0⁻3), high levels of self-efficacy (M = 3.1, SD = 0.7, range 1⁻4), and low barriers (M = 1.4, SD = 0.6, range 0⁻4) to engage in healthy eating but total mean HEI scores needed improvement (M = 54.8, SD = 10.9, range 27.1⁻70.0). Participants consumed significantly higher empty calories and lower whole fruits, dairy, and total protein foods than the national average. Barriers to healthy eating (b = -12.13, p = 0.01) and the interaction between age and barriers (b = 0.25, p = 0.02) were most strongly associated with lower HEI scores. Younger African Americans with the highest barriers to healthy eating had the lowest HEI scores. Culturally appropriate interventions targeting empty calories, barriers to healthy eating, and knowledge of the Dietary Guidelines for Americans are needed for African Americans.

Predicting disease onset in clinically healthy people

Virtually all human disease is induced by oxidative stress. Oxidative stress, which is caused by toxic environmental exposure, the presence of disease, lifestyle choices, stress, chronic inflammation or combinations of these, is responsible for most disease. Oxidative stress from all sources is additive and it is the total oxidative stress from all sources that induces the onset of most disease. Oxidative stress leads to lipid peroxidation, which in turn produces Malondialdehyde. Serum malondialdehyde level is an additive parameter resulting from all sources of oxidative stress and, therefore, is a reliable indicator of total oxidative stress which can be used to predict the onset of disease in clinically asymptomatic individuals and to suggest the need for treatment that can prevent much human disease.

An effectiveness-implementation hybrid trial study protocol targeting posttraumatic stress disorder and comorbidity

BACKGROUND

Each year in the USA, 1.5-2.5 million Americans are so severely injured that they require inpatient hospitalization. Multiple conditions including posttraumatic stress disorder (PTSD), alcohol and drug use problems, depression, and chronic medical conditions are endemic among physical trauma survivors with and without traumatic brain injuries.

METHODS/DESIGN

The trauma survivors outcomes and support (TSOS) effectiveness-implementation hybrid trial is designed to test the delivery of high-quality screening and intervention for PTSD and comorbidities across 24 US level I trauma center sites. The pragmatic trial aims to recruit 960 patients. The TSOS investigation employs a stepped wedge cluster randomized design in which sites are randomized sequentially to initiate the intervention. Patients identified by a 10-domain electronic health record screen as high risk for PTSD are formally assessed with the PTSD Checklist for study entry. Patients randomized to the intervention condition will receive stepped collaborative care, while patients randomized to the control condition will receive enhanced usual care. The intervention training begins with a 1-day on-site workshop in the collaborative care intervention core elements that include care management, medication, cognitive behavioral therapy, and motivational-interviewing elements targeting PTSD and comorbidity. The training is followed by site supervision from the study team. The investigation aims to determine if intervention patients demonstrate significant reductions in PTSD and depressive symptoms, suicidal ideation, alcohol consumption, and improvements in physical function when compared to control patients. The study uses implementation science conceptual frameworks to evaluate the uptake of the intervention model. At the completion of the pragmatic trial, results will be presented at an American College of Surgeons' policy summit. Twenty-four representative US level I trauma centers have been selected for the study, and the protocol is being rolled out nationally.

DISCUSSION

The TSOS pragmatic trial simultaneously aims to establish the effectiveness of the collaborative care intervention targeting PTSD and comorbidity while also addressing sustainable implementation through American College of Surgeons' regulatory policy. The TSOS effectiveness-implementation hybrid design highlights the importance of partnerships with professional societies that can provide regulatory mandates targeting enhanced health care system sustainability of pragmatic trial results.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02655354 . Registered 27 July 2015.

Individualized Absolute Risk Calculations for Persons with Multiple Chronic Conditions: Embracing Heterogeneity, Causality, and Competing Events

Approximately 75% of adults over the age of 65 years are affected by two or more chronic medical conditions. We provide a conceptual justification for individualized absolute risk calculators for competing patient-centered outcomes (PCO) (i.e. outcomes deemed important by patients) and patient reported outcomes (PRO) (i.e. outcomes patients report instead of physiologic test results). The absolute risk of an outcome is the probability that a person receiving a given treatment will experience that outcome within a pre-defined interval of time, during which they are simultaneously at risk for other competing outcomes. This allows for determination of the likelihood of a given outcome with and without a treatment. We posit that there are heterogeneity of treatment effects among patients with multiple chronic conditions (MCC) largely depends on those coexisting conditions. We outline the development of an individualized absolute risk calculator for competing outcomes using propensity score methods that strengthen causal inference for specific treatments. Innovations include the key concept that any given outcome may or may not concur with any other outcome and that these competing outcomes do not necessarily preclude other outcomes. Patient characteristics and MCC will be the primary explanatory factors used in estimating the heterogeneity of treatment effects on PCO and PRO. This innovative method may have wide-spread application for determining individualized absolute risk calculations for competing outcomes. Knowing the probabilities of outcomes in absolute terms may help the burgeoning population of patients with MCC who face complex treatment decisions.

A Biobehavioral Framework to Address the Emerging Challenge of Multimorbidity

Multimorbidity, the co-occurrence of multiple physical or psychological illnesses, is prevalent particularly among older adults. The number of Americans with multiple chronic diseases is projected to increase from 57 million in 2000 to 81 million in 2020. However, behavioral medicine and health psychology, while focusing on the co-occurrence of psychological/psychiatric disorders with primary medical morbidities, have historically tended to ignore the co-occurrence of primary medical comorbidities, such as diabetes and cancer, and their biopsychosocial implications. This approach may hinder our ecologically valid understanding of the etiology, prevention, and treatment for individual patients with multimorbidity. In this selective review, we propose a heuristic behavioral framework for the etiology of multimorbidity. More acknowledgment and systematic research on multiple, co-existing disorders in behavioral medicine are consistent with the biopsychosocial model's emphasis on treating the "whole person," which means not considering any single illness, its symptoms, risk factors, or mechanisms, in isolation. As systems analytics, big data, machine learning, and mixed-model trajectory analyses, among others, come online and become more widely available, we may be able to tackle multimorbidity more holistically, efficiently, and satisfactorily.

Prevalence of Combined Somatic and Mental Health Multimorbidity: Patterns by Age, Sex, and Race/Ethnicity

BACKGROUND

The coexistence of chronic mental health conditions with somatic conditions (somatic-mental multimorbidity, or SMM) is common and has been associated with greater symptom burden and functional impairment, higher costs, and excess mortality. However, most existing literature focused on the co-occurrence of an index mental health condition with specific additional conditions. By contrast, we studied the prevalence and patterns of SMM more broadly considering 19 selected conditions, and we focused on differences by age, sex, and race/ethnicity.

METHODS

The Rochester Epidemiology Project (REP) records-linkage system was used to identify all residents of Olmsted County, MN, on April 1, 2010. We identified individuals with each of 19 common chronic conditions, including 5 mental health conditions, using the International Classification of Diseases, ninth revision (ICD-9) codes received from any health care provider between April 1, 2005 and March 31, 2010.

RESULTS

Among the 138,858 residents of the county, 52.4% were women, and 7.9% had SMM. SMM increased steeply with older age, was 1.7 times more common in women, and was lower in Asians compared with whites. Of the 10,903 persons with SMM, 7,739 (71.0%) were younger than 65 years. Depressive and anxiety disorders were the most common conditions involved in SMM. The dyads that were observed more frequently or less frequently than expected by chance varied in composition by age and sex.

CONCLUSIONS

SMM that reaches medical attention is highly prevalent across all age groups, is more frequent in women, is less frequent in Asians, and encompasses a wide range of conditions.

Health-enhancing multibehavior and medical multimorbidity

OBJECTIVE

To examine the association of multibehavior on multimorbidity.

PATIENTS AND METHODS

Data from the 2005-2006 National Health and Nutrition Examination Survey were used. The study duration was from October 20, 2013, through December 16, 2014. A multimorbidity index variable was created that indicated the number of 14 morbidities that each patient had. A multibehavior index variable was created that indicated the number of 4 health-enhancing behaviors each participant had; physical activity was assessed via accelerometry, dietary behavior was assessed via an interview, smoking was determined via cotinine levels, and sleep duration was self-reported.

RESULTS

For the entire sample of 2048 participants, those with 1, 2, 3, and 4 health behaviors, compared with 0 health behaviors, had a 35% (odds ratio [OR], 0.65; 95% CI, 0.47-0.90; P=.01), 44% (OR, 0.56; 95% CI, 0.38-0.82; P=.006), 63% (OR, 0.37; 95% CI, 0.26-0.51; P<.001), and 69% (OR, 0.31; 95% CI, 0.19-0.52; P<.001) reduced odds of being multimorbid, respectively. Only physical activity (β=-.46) and sleep (β=-.23) were independently associated with multimorbidity, and only 2 health behavior combinations were associated with multimorbidity: physical activity and sleep (β=-.17) and physical activity and nonsmoking (β=-.16).

CONCLUSIONS

Americans engaging in more health behaviors were less likely to be multimorbid. Physical activity was independently, as well is in combination with other health behaviors, associated with multimorbidity. Implications for developing a multibehavior-multimorbidity framework to treat the patients' holistic needs is discussed.

[A way of helping "Mr. Minotaur" and "Ms. Ariadne" to exit from the multiple morbidity labyrinth: the "master problems"]

Multiple morbidity seems to be "infinite" and so is not easy to make useful decisions. A new concept is introduced: the "master problems", as a qualitative method to facilitate the exit from this maze of multiple morbidity. Metaphors from the art world have been used to teach this concept. These "master problems" generally remain hidden and can only "unravel" between the interstices of multiple morbidity, when the details of the system that defines the problem are explained. A problem with "energy" or a "master problem" is complex, multiple and dramatic or theatrical--everything in the clinical history history make us look into that particular question. It is what gives us a blow to the stomach, which causes our hearts to beat faster, that moves us on many levels, which has a high "density of emotions", human elements, social symbols, and opens solutions in a patient.

Prevalence of multimorbidity in a geographically defined American population: patterns by age, sex, and race/ethnicity

OBJECTIVE

To describe the prevalence of multimorbidity involving 20 selected chronic conditions in a geographically defined US population, emphasizing age, sex, and racial/ethnic differences.

PATIENTS AND METHODS

Using the Rochester Epidemiology Project records linkage system, we identified all residents of Olmsted County, Minnesota, on April 1, 2010, and electronically extracted the International Classification of Diseases, Ninth Revision codes associated with all health care visits made between April 1, 2005, and March 31, 2010 (5-year capture frame). Using these codes, we defined the 20 common chronic conditions recommended by the US Department of Health and Human Services. We counted only persons who received at least 2 codes for a given condition separated by more than 30 days, and we calculated the age-, sex-, and race/ethnicity-specific prevalence of multimorbidity.

RESULTS

Of the 138,858 study participants, 52.4% were women (n=72,732) and 38.9% had 1 or more conditions (n=54,012), 22.6% had 2 or more conditions (n=31,444), and 4.9% had 5 or more conditions (n=6853). The prevalence of multimorbidity (≥2 conditions) increased steeply with older age and reached 77.3% at 65 years and older. However, the absolute number of people affected by multimorbidity was higher in those younger than 65 years. Although the prevalence of multimorbidity was similar in men and women overall, the most common dyads and triads of conditions varied by sex. Compared with white persons, the prevalence of multimorbidity was slightly higher in black persons and slightly lower in Asian persons.

CONCLUSION

Multimorbidity is common in the general population; it increases steeply with older age, has different patterns in men and women, and varies by race/ethnicity.

Aging and the burden of multimorbidity: associations with inflammatory and anabolic hormonal biomarkers

BACKGROUND

Multimorbidity increases with aging, but risk factors beyond age are unknown.

OBJECTIVE

To investigate the association of inflammatory and anabolic hormonal biomarkers with presence and prospective development of multimorbidity.

METHODS

Nine-year longitudinal study of 1018 participants aged 60 years or older (InCHIANTI Study). Multimorbidity was evaluated at baseline and follow-up visits as number of diagnosed diseases from a predefined list of 15 candidate chronic conditions, defined according to standard clinical criteria. Linear mixed models were used to test cross-sectional and longitudinal associations between candidate biomarkers and multimorbidity.

RESULTS

At baseline, multimorbidity was significantly higher in older participants (p < .001) and higher IL-6, IL-1ra, TNF-α receptor II (TNFAR2), and lower dehydroepiandrosterone sulfate were associated with higher number of diseases, independent of age, sex, body mass index, and education. The rate of longitudinal increase in number of chronic diseases was significantly steeper in participants who were older at baseline (p < .001). In addition, higher baseline IL-6 and steeper increase of IL-6 levels were significantly and independently associated with a steeper increase in multimorbidity over time (p < .001 and p = .003, respectively). Sensitivity analyses, performed using 15 different models obtained by removing each of 15 conditions included in the original list of candidate diseases, confirmed that results were not driven by any specific condition.

CONCLUSIONS

Accumulation of chronic diseases accelerates at older ages and in persons with higher baseline levels and steeper increase over time of IL-6. High IL-6 and increase in IL-6 may serve as early warning sign to better target interventions aimed at reducing the burden of multimorbidity.

The role of comorbidities in patients' hypertension self-management

OBJECTIVE

We sought to understand barriers to hypertension self-management in patients with hypertension and comorbidities.

METHODS

We conducted semi-structured, qualitative interviews with 48 patients with uncontrolled hypertension and at least one comorbidity to learn about beliefs and behaviors that might affect hypertension self-management. Using a grounded theory strategy, we analyzed interview transcripts detailing patients' hypertension self-management behaviors vis-à-vis a framework including Explanatory Models-a patient's understanding of the pathophysiology, cause, course, treatment, and severity of an illness, such as hypertension.

RESULTS

We identified four factors that interfered with hypertension self-management. (1) Interdependence: Participants saw hypertension as interconnected to their comorbidities and subsequently had difficulty separating information about their illnesses. (2) Low priority: Compared to other conditions, participants assigned hypertension a lower priority. (3) Conflicts: Participants struggled with conflicts between hypertension self-management practices and those for comorbidities. (4) Managing multiple medications: Polypharmacy led to patients' confusion and concern about taking medications as prescribed.

DISCUSSION

Participants did not experience hypertension as a discreet clinical condition; rather, they self-managed hypertension concurrently with other conditions, leading to a breakdown in hypertension self-management. We provide strategies to address each of the four barriers to better equip providers in addressing their clinically salient concerns.

Understanding the context of health for persons with multiple chronic conditions: moving from what is the matter to what matters

PURPOSE

An isolated focus on 1 disease at a time is insufficient to generate the scientific evidence needed to improve the health of persons living with more than 1 chronic condition. This article explores how to bring context into research efforts to improve the health of persons living with multiple chronic conditions (MCC).

METHODS

Forty-five experts, including persons with MCC, family and friend caregivers, researchers, policy makers, funders, and clinicians met to critically consider 4 aspects of incorporating context into research on MCC: key contextual factors, needed research, essential research methods for understanding important contextual factors, and necessary partnerships for catalyzing collaborative action in conducting and applying research.

RESULTS

Key contextual factors involve complementary perspectives across multiple levels: public policy, community, health care systems, family, and person, as well as the cellular and molecular levels where most research currently is focused. Needed research involves moving from a disease focus toward a person-driven, goal-directed research agenda. Relevant research methods are participatory, flexible, multilevel, quantitative and qualitative, conducive to longitudinal dynamic measurement from diverse data sources, sufficiently detailed to consider what works for whom in which situation, and generative of ongoing communities of learning, living and practice. Important partnerships for collaborative action include cooperation among members of the research enterprise, health care providers, community-based support, persons with MCC and their family and friend caregivers, policy makers, and payers, including government, public health, philanthropic organizations, and the business community.

CONCLUSION

Consistent attention to contextual factors is needed to enhance health research for persons with MCC. Rigorous, integrated, participatory, multimethod approaches to generate new knowledge and diverse partnerships can be used to increase the relevance of research to make health care more sustainable, safe, equitable and effective, to reduce suffering, and to improve quality of life.

Multiple chronic conditions among US adults: a 2012 update

The objective of this research was to update earlier estimates of prevalence rates of single chronic conditions and multiple (>2) chronic conditions (MCC) among the noninstitutionalized, civilian US adult population. Data from the 2012 National Health Interview Survey (NHIS) were used to generate estimates of MCC for US adults and by select demographic characteristics. Approximately half (117 million) of US adults have at least one of the 10 chronic conditions examined (ie, hypertension, coronary heart disease, stroke, diabetes, cancer, arthritis, hepatitis, weak or failing kidneys, current asthma, or chronic obstructive pulmonary disease [COPD]). Furthermore, 1 in 4 adults has MCC.