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Torrell G, Puente D, Jacques-Aviñó C, Carrasco-Ribelles LA, Violán C, López-Jiménez T, Royano V, Cantón AM, Medina-Perucha L, Rodríguez-Giralt I, Berenguera A. Characterisation, symptom pattern and symptom clusters from a retrospective cohort of Long COVID patients in primary care in Catalonia. BMC Infect Dis 2024; 24:82. [PMID: 38225587 PMCID: PMC10789045 DOI: 10.1186/s12879-023-08954-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 12/27/2023] [Indexed: 01/17/2024] Open
Abstract
BACKGROUND Around 10% of people infected by SARS-COV-2 report symptoms that persist longer than 3 months. Little has been reported about sex differences in symptoms and clustering over time of non-hospitalised patients in primary care settings. METHODS This is a descriptive study of a cohort of mainly non-hospitalized patients with a persistence of symptoms longer than 3 months from the clinical onset in co-creation with the Long Covid Catalan affected group using an online survey. Recruitment was from March 2020 to June 2021. Exclusion criteria were being admitted to an ICU, < 18 years of age and not living in Catalonia. We focused on 117 symptoms gathered in 18 groups and performed cluster analysis over the first 21 days of infection, at 22-60 days, and ≥ 3 months. RESULTS We analysed responses of 905 participants (80.3% women). Median time between symptom onset and the questionnaire response date was 8.7 months. General symptoms (as fatigue) were the most prevalent with no differences by sex, age, or wave although its frequency decreased over time (from 91.8 to 78.3%). Dermatological (52.1% in women, 28.5% in men), olfactory (34.9% women, 20.9% men) and neurocognitive symptoms (70.1% women, 55.8% men) showed the greatest differences by sex. Cluster analysis showed five clusters with a predominance of Taste & smell (24.9%) and Multisystemic clusters (26.5%) at baseline and _Multisystemic (34.59%) and Heterogeneous (24.0%) at ≥3 months. The Multisystemic cluster was more prevalent in men. The Menstrual cluster was the most stable over time, while most transitions occurred from the Heterogeneous cluster to the Multisystemic cluster and from Taste & smell to Heterogeneous. CONCLUSIONS General symptoms were the most prevalent in both sexes at three-time cut-off points. Major sex differences were observed in dermatological, olfactory and neurocognitive symptoms. The increase of the Heterogeneous cluster might suggest an adaptation to symptoms or a non-specific evolution of the condition which can hinder its detection at medical appointments. A carefully symptom collection and patients' participation in research may generate useful knowledge about Long Covid presentation in primary care settings.
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Affiliation(s)
- Gemma Torrell
- Centre d'Atenció Primària Les Indianes, Gerència Territorial de Barcelona, Institut Català de la Salut, Barcelona, Spain
| | - Diana Puente
- Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain.
- Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain.
- Network for Research on Chronicity, Primary Care, and Health Promotion (RICAPPS) (RD21/0016/0029) Insitituto de Salud Carlos III, Madrid, Spain.
| | - Constanza Jacques-Aviñó
- Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
| | - Lucia A Carrasco-Ribelles
- Network for Research on Chronicity, Primary Care, and Health Promotion (RICAPPS) (RD21/0016/0029) Insitituto de Salud Carlos III, Madrid, Spain
- Unitat de Suport a la Recerca Metropolitana Nord, Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Mataró, Spain
- Grup de REcerca en Impacte de les Malalties Cròniques i les seves Trajectòries (GRIMTra), (2021 SGR 01537), Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAPJGol), 08008, Barcelona, Spain
| | - Concepció Violán
- Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain
- Network for Research on Chronicity, Primary Care, and Health Promotion (RICAPPS) (RD21/0016/0029) Insitituto de Salud Carlos III, Madrid, Spain
- Unitat de Suport a la Recerca Metropolitana Nord, Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Mataró, Spain
- Grup de REcerca en Impacte de les Malalties Cròniques i les seves Trajectòries (GRIMTra), (2021 SGR 01537), Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAPJGol), 08008, Barcelona, Spain
- Direcció d'Atenció Primària Metropolitana Nord Institut Català de Salut, Barcelona, Spain
| | - Tomás López-Jiménez
- Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
- Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain
| | - Veronica Royano
- Universitat Politècnica de Catalunya BarcelonaTech (UPC), Barcelona, Spain
- Members of the Col·lectiu d'Afectades i Afectats Persistents per COVID-19 a Catalunya, Barcelona, Spain
| | - Alba Molina Cantón
- Members of the Col·lectiu d'Afectades i Afectats Persistents per COVID-19 a Catalunya, Barcelona, Spain
| | - Laura Medina-Perucha
- Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
| | - Israel Rodríguez-Giralt
- Internet Interdisciplinary Institute (IN3), Universitat Oberta de Catalunya, Barcelona, Spain
| | - Anna Berenguera
- Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
- Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain
- Network for Research on Chronicity, Primary Care, and Health Promotion (RICAPPS) (RD21/0016/0029) Insitituto de Salud Carlos III, Madrid, Spain
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de Homdedeu M, Sanchez-Moral L, Violán C, Ràfols N, Ouchi D, Martín B, Peinado MA, Rodríguez-Cortés A, Arch-Sisquella M, Perez-Zsolt D, Muñoz-Basagoiti J, Izquierdo-Useros N, Salvador B, Matllo J, López-Serrano S, Segalés J, Vilaplana C, Torán-Monserrat P, Morros R, Monfà R, Sarrias MR, Cardona PJ. Mycobacterium manresensis induces trained immunity in vitro. iScience 2023; 26:106873. [PMID: 37250788 PMCID: PMC10182650 DOI: 10.1016/j.isci.2023.106873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 04/24/2023] [Accepted: 05/09/2023] [Indexed: 05/31/2023] Open
Abstract
The COVID-19 pandemic posed a global health crisis, with new severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variants weakening vaccine-driven protection. Trained immunity could help tackle COVID-19 disease. Our objective was to analyze whether heat-killed Mycobacterium manresensis (hkMm), an environmental mycobacterium, induces trained immunity and confers protection against SARS-CoV-2 infection. To this end, THP-1 cells and primary monocytes were trained with hkMm. The increased secretion of tumor necrosis factor alpha (TNF-α), interleukin (IL)-6, IL-1β, and IL-10, metabolic activity, and changes in epigenetic marks suggested hkMm-induced trained immunity in vitro. Healthcare workers at risk of SARS-CoV-2 infection were enrolled into the MANRECOVID19 clinical trial (NCT04452773) and were administered Nyaditum resae (NR, containing hkMm) or placebo. No significant differences in monocyte inflammatory responses or the incidence of SARS-CoV-2 infection were found between the groups, although NR modified the profile of circulating immune cell populations. Our results show that M. manresensis induces trained immunity in vitro but not in vivo when orally administered as NR daily for 14 days.
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Affiliation(s)
- Miquel de Homdedeu
- Innate Immunity Group, Germans Trias i Pujol Research Institute (IGTP), 08916 Badalona, Spain
- Experimental Tuberculosis Unit, Germans Trias i Pujol Research Institute (IGTP), 08916 Badalona, Spain
- Department of Genetics and Microbiology, Autonomous University of Barcelona (UAB), 08193 Bellaterra, Spain
| | - Lidia Sanchez-Moral
- Innate Immunity Group, Germans Trias i Pujol Research Institute (IGTP), 08916 Badalona, Spain
| | - Concepció Violán
- Jordi Gol University Research Institute in Primary Care, 08007 Barcelona, Spain
- North Metropolitan Research Support Unit, Jordi Gol University Research Institute in Primary Care (IDIAP Jordi Gol), Mataró, Spain
- Northern Metropolitan Primary Care Management, Catalan Institute of Health, 08916 Badalona, Spain
- Germans Trias i Pujol Research Institute (IGTP), 08916 Badalona, Spain
- Autonomous University of Barcelona (UAB), 08193 Bellaterra, Spain
| | - Neus Ràfols
- Innate Immunity Group, Germans Trias i Pujol Research Institute (IGTP), 08916 Badalona, Spain
| | - Dan Ouchi
- Jordi Gol University Research Institute in Primary Care, 08007 Barcelona, Spain
| | - Berta Martín
- Program of Predictive and Personalized Medicine of Cancer, Germans Trias i Pujol Research Institute (PMPPC-IGTP), 08916 Badalona, Spain
| | - Miguel A Peinado
- Program of Predictive and Personalized Medicine of Cancer, Germans Trias i Pujol Research Institute (PMPPC-IGTP), 08916 Badalona, Spain
| | - Alhelí Rodríguez-Cortés
- Department of Pharmacology, Toxicology, and Therapeutics, Veterinary Faculty, Autonomous University of Barcelona, 08193 Bellaterra, Spain
| | - Marta Arch-Sisquella
- Experimental Tuberculosis Unit, Germans Trias i Pujol Research Institute (IGTP), 08916 Badalona, Spain
| | | | | | - Nuria Izquierdo-Useros
- IrsiCaixa AIDS Research Institute, 08916 Badalona, Spain
- Centre for Biomedical Research on Infectious Diseases (CIBERINFEC), Madrid, Spain
| | - Betlem Salvador
- Jordi Gol University Research Institute in Primary Care, 08007 Barcelona, Spain
| | - Joan Matllo
- Department of Prevention and Risks, Germans Trias i Pujol University Hospital, Northern Metropolitan Territorial Management, Catalan Health Institute, 08916 Badalona, Spain
| | - Sergi López-Serrano
- Joint IRTA-UAB Research Unit in Animal Health, Animal Health Research Center (CReSA), Autonomous University of Barcelona (UAB), 08193 Bellaterra, Spain
- Institute of Agrifood Research and Technology, Animal Health Program, Animal Health Research Center (CReSA), Autonomous University of Barcelona (UAB), 08193 Bellaterra, Spain
- OIE Collaborating Centre for the Research and Control of Emerging and Re-Emerging Swine Diseases in Europe (IRTA-CReSA), 08193 Bellaterra, Spain
| | - Joaquim Segalés
- Joint IRTA-UAB Research Unit in Animal Health, Animal Health Research Center (CReSA), Autonomous University of Barcelona (UAB), 08193 Bellaterra, Spain
- OIE Collaborating Centre for the Research and Control of Emerging and Re-Emerging Swine Diseases in Europe (IRTA-CReSA), 08193 Bellaterra, Spain
- Department of Animal Health and Anatomy, Faculty of Veterinary Medicine, Autonomous University of Barcelona (UAB), 08193 Bellaterra, Spain
| | - Cristina Vilaplana
- Experimental Tuberculosis Unit, Germans Trias i Pujol Research Institute (IGTP), 08916 Badalona, Spain
- Department of Genetics and Microbiology, Autonomous University of Barcelona (UAB), 08193 Bellaterra, Spain
- Centre for Biomedical Research on Respiratory Diseases (CIBERES), Madrid, Spain
- Microbiology Department, Laboratori Clínic Metropolitana Nord, Germans Trias i Pujol University Hospital, 08916 Badalona, Spain
- Direcció Clínica Territorial de Malalties Infeccioses i Salut Internacional de Gerència Territorial Metropolitana Nord, Barcelona, Spain
| | - Pere Torán-Monserrat
- Jordi Gol University Research Institute in Primary Care, 08007 Barcelona, Spain
- North Metropolitan Research Support Unit, Jordi Gol University Research Institute in Primary Care (IDIAP Jordi Gol), Mataró, Spain
- Northern Metropolitan Primary Care Management, Catalan Institute of Health, 08916 Badalona, Spain
- Germans Trias i Pujol Research Institute (IGTP), 08916 Badalona, Spain
| | - Rosa Morros
- Jordi Gol University Research Institute in Primary Care, 08007 Barcelona, Spain
| | - Ramon Monfà
- Jordi Gol University Research Institute in Primary Care, 08007 Barcelona, Spain
| | - Maria-Rosa Sarrias
- Innate Immunity Group, Germans Trias i Pujol Research Institute (IGTP), 08916 Badalona, Spain
- Centre for Biomedical Research on Liver and Digestive Diseases (CIBEREHD), Madrid, Spain
| | - Pere-Joan Cardona
- Experimental Tuberculosis Unit, Germans Trias i Pujol Research Institute (IGTP), 08916 Badalona, Spain
- Department of Genetics and Microbiology, Autonomous University of Barcelona (UAB), 08193 Bellaterra, Spain
- Centre for Biomedical Research on Respiratory Diseases (CIBERES), Madrid, Spain
- Microbiology Department, Laboratori Clínic Metropolitana Nord, Germans Trias i Pujol University Hospital, 08916 Badalona, Spain
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Rando-Matos Y, Pons-Vigués M, Rodriguez-Blanco T, Ripoll J, Llobera J, Morán J, Ballvé-Moreno JL, Violán C, Bolíbar B. Effect of comprehensive smoke-free legislation on asthma and coronary disease trends in Spanish primary care patients. Eur J Public Health 2019; 28:553-559. [PMID: 29401282 DOI: 10.1093/eurpub/cky010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background To examine the impact of comprehensive smoke-free legislation (SFL) (Law 42/2010) on the incidence and prevalence of adult asthma and coronary disease in primary health care (PHC) patients from three Spanish regions, overall and stratified by sex. Methods Longitudinal observational study conducted between 2007 and 2013 in the population over 15 years of age assigned to 66 PHC teams in Catalonia, Navarre and the Balearic Islands. Crude rates and age-standardized (truncated: asthma ≥ 16 years and coronary disease ≥ 35 years) incidence and prevalence rates using the direct method based on the European Standard Population were estimated based on data from PHC electronic health records. Joinpoint analysis was used to analyse the trends of age-standardized incidence and prevalence rates. Trends were expressed as annual percentage change and average annual percent change (AAPC). Results The standardized asthma incidence rate showed a non-significant downward trend and the standardized prevalence rates rose significantly in the three regions. Standardized coronary disease incidence and prevalence rates were considerably higher for men than for women in all regions. The standardized coronary disease incidence rates in Catalonia (AAPC: -8.00%, 95% CI: -10.46; -5.47) and Navarre (AAPC: -3.66%, 95% CI: -4.95;-2.35) showed a significant downward trend from 2007 to 2013, overall and by sex. The standardized coronary disease prevalence trend rate increased significantly in the whole period in Catalonia and the Balearic Islands, although a non-significant downward trend was observed from 2010 in Catalonia. Conclusion No changes in the trends of adult asthma and coronary disease in PHC Spanish patients were detected after the introduction of comprehensive SFL.
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Affiliation(s)
- Yolanda Rando-Matos
- Centre d'Atenció Primària (CAP) Florida Nord. Gerència d'Àmbit d'Atenció Primària Metropolitana Sud, Institut Català de la Salut (ICS), Hospitalet de Llobregat, Barcelona, Spain.,Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain
| | - Mariona Pons-Vigués
- Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain.,Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain.,Universitat de Girona, Girona, Spain
| | - Teresa Rodriguez-Blanco
- Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain.,Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain
| | - Joana Ripoll
- Primary Care Research Unit of Mallorca, Baleares Health Services-Ibsalut, Palma, Spain.,Instituto de Investigación Sanitaria les Illes Balears (IdSBA), Hospital Universitario Son Espases, Palma, Spain
| | - Joan Llobera
- Primary Care Research Unit of Mallorca, Baleares Health Services-Ibsalut, Palma, Spain.,Instituto de Investigación Sanitaria les Illes Balears (IdSBA), Hospital Universitario Son Espases, Palma, Spain
| | - Julio Morán
- Consultorio de Barásoain (Equipo de Atención Primaria de Tafalla), Servicio Navarro de Salud, Navarra, Spain
| | - Josep Lluís Ballvé-Moreno
- Centre d'Atenció Primària (CAP) Florida Nord. Gerència d'Àmbit d'Atenció Primària Metropolitana Sud, Institut Català de la Salut (ICS), Hospitalet de Llobregat, Barcelona, Spain.,Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain
| | - Concepció Violán
- Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain.,Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain
| | - Bonaventura Bolíbar
- Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain.,Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain
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Amell A, Roso-Llorach A, Palomero L, Cuadras D, Galván-Femenía I, Serra-Musach J, Comellas F, de Cid R, Pujana MA, Violán C. Disease networks identify specific conditions and pleiotropy influencing multimorbidity in the general population. Sci Rep 2018; 8:15970. [PMID: 30374096 PMCID: PMC6206057 DOI: 10.1038/s41598-018-34361-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 10/15/2018] [Indexed: 01/16/2023] Open
Abstract
Multimorbidity is an emerging topic in public health policy because of its increasing prevalence and socio-economic impact. However, the age- and gender-dependent trends of disease associations at fine resolution, and the underlying genetic factors, remain incompletely understood. Here, by analyzing disease networks from electronic medical records of primary health care, we identify key conditions and shared genetic factors influencing multimorbidity. Three types of diseases are outlined: "central", which include chronic and non-chronic conditions, have higher cumulative risks of disease associations; "community roots" have lower cumulative risks, but inform on continuing clustered disease associations with age; and "seeds of bursts", which most are chronic, reveal outbreaks of disease associations leading to multimorbidity. The diseases with a major impact on multimorbidity are caused by genes that occupy central positions in the network of human disease genes. Alteration of lipid metabolism connects breast cancer, diabetic neuropathy and nutritional anemia. Evaluation of key disease associations by a genome-wide association study identifies shared genetic factors and further supports causal commonalities between nervous system diseases and nutritional anemias. This study also reveals many shared genetic signals with other diseases. Collectively, our results depict novel population-based multimorbidity patterns, identify key diseases within them, and highlight pleiotropy influencing multimorbidity.
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Affiliation(s)
- A Amell
- Department of Mathematics, Technical University of Catalonia, Castelldefels, Barcelona, 08860, Catalonia, Spain
| | - A Roso-Llorach
- Jordi Gol University Institute for Research Primary Healthcare (IDIAP Jordi Gol), Barcelona, 08007, Catalonia, Spain
- Autonomous University of Barcelona, Bellaterra, 08193, Catalonia, Spain
| | - L Palomero
- ProCURE, Catalan Institute of Oncology (ICO), Oncobell, Bellvitge Institute for Biomedical Research (IDIBELL), L'Hospitalet del Llobregat, Barcelona, 08908, Catalonia, Spain
| | - D Cuadras
- Statistics Department, Foundation Sant Joan de Déu, Esplugues, 08950, Catalonia, Spain
| | - I Galván-Femenía
- GCAT-Genomes for Life, Germans Trias i Pujol Health Sciences Research Institute (IGTP), Program for Predictive and Personalized Medicine of Cancer (IMPPC), Badalona, 08916, Catalonia, Spain
| | - J Serra-Musach
- ProCURE, Catalan Institute of Oncology (ICO), Oncobell, Bellvitge Institute for Biomedical Research (IDIBELL), L'Hospitalet del Llobregat, Barcelona, 08908, Catalonia, Spain
| | - F Comellas
- Department of Mathematics, Technical University of Catalonia, Castelldefels, Barcelona, 08860, Catalonia, Spain
| | - R de Cid
- GCAT-Genomes for Life, Germans Trias i Pujol Health Sciences Research Institute (IGTP), Program for Predictive and Personalized Medicine of Cancer (IMPPC), Badalona, 08916, Catalonia, Spain.
| | - M A Pujana
- ProCURE, Catalan Institute of Oncology (ICO), Oncobell, Bellvitge Institute for Biomedical Research (IDIBELL), L'Hospitalet del Llobregat, Barcelona, 08908, Catalonia, Spain.
| | - C Violán
- Jordi Gol University Institute for Research Primary Healthcare (IDIAP Jordi Gol), Barcelona, 08007, Catalonia, Spain.
- Autonomous University of Barcelona, Bellaterra, 08193, Catalonia, Spain.
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Ricci-Cabello I, Violán C, Foguet-Boreu Q, Mounce LTA, Valderas JM. Impact of multi-morbidity on quality of healthcare and its implications for health policy, research and clinical practice. A scoping review. Eur J Gen Pract 2015; 21:192-202. [PMID: 26232238 DOI: 10.3109/13814788.2015.1046046] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
The simultaneous presence of multiple conditions in one patient (multi-morbidity) is a key challenge facing healthcare systems globally. It potentially threatens the coordination, continuity and safety of care. In this paper, we report the results of a scoping review examining the impact of multi-morbidity on the quality of healthcare. We used its results as a basis for a discussion of the challenges that research in this area is currently facing. In addition, we discuss its implications for health policy and clinical practice. The review identified 37 studies focussing on multi-morbidity but using conceptually different approaches. Studies focusing on 'comorbidity' (i.e. the 'index disease' approach) suggested that quality may be enhanced in the presence of synergistic conditions, and impaired by antagonistic or neutral conditions. Studies on 'multi-morbidity' (i.e. multiplicity of problems) and 'morbidity burden' (i.e. the total severity of conditions) suggested that increasing number of conditions and severity may be associated with better quality of healthcare when measured by process or intermediate outcome indicators, but with worse quality when patient-centred measures are used. However, issues related to the conceptualization and measurement of multi-morbidity (inconsistent across studies) and of healthcare quality (restricted to evaluations for each separate condition without incorporating considerations about multi-morbidity itself and its implications for management) compromised the generalizability of these observations. Until these issues are addressed and robust evidence becomes available, clinicians should apply minimally invasive and patient-centred medicine when delivering care for clinically complex patients. Health systems should focus on enhancing primary care centred coordination and continuity of care.
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Affiliation(s)
- Ignacio Ricci-Cabello
- a Nuffield Department of Primary Care Health Sciences , University of Oxford , Oxford , UK
| | - Concepció Violán
- b Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol) , Barcelona , Spain.,c Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès) , Spain
| | - Quinti Foguet-Boreu
- b Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol) , Barcelona , Spain.,c Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès) , Spain.,d Department of Medical Sciences , School of Medicine, University of Girona , Girona , Spain
| | - Luke T A Mounce
- e Institute for Health Research, University of Exeter Collaboration for Academic Primary Care (APEx), University of Exeter Medical School, University of Exeter , Exeter , UK
| | - Jose M Valderas
- a Nuffield Department of Primary Care Health Sciences , University of Oxford , Oxford , UK.,b Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol) , Barcelona , Spain.,c Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès) , Spain.,e Institute for Health Research, University of Exeter Collaboration for Academic Primary Care (APEx), University of Exeter Medical School, University of Exeter , Exeter , UK.,f CIBER en Epidemiologia y Salud P blica (CIBERESP) , Barcelona , Spain
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Affiliation(s)
- F Carballo
- Médico Adjunto de Digestivo, Hospital Universitario de Guadalajara, Universidad de Alcalá, Madrid, Spain
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