Predictors of basic and instrumental activities of daily living among older adults with multiple chronic conditions

BACKGROUND

Understanding the predictors of functional status can be useful for improving modifiable predictors or identifying at-risk populations. Researchers have examined the predictors of functional status in older adults, but there has not been sufficient study in this field in older adults with multiple chronic conditions, especially in Iran. Consequently, the results of this body of research may not be generalizable to Iran. Therefore, this study was conducted to determine the predictors of functional status in Iranian older adults with multiple chronic conditions.

METHODS

In this cross-sectional study, 118 Iranian older adults with multiple chronic conditions were recruited from December 2022 to September 2023. They were invited to respond to questionnaires inquiring about their demographic and health information, basic activities of daily living (BADL) and instrumental activities of daily living (IADL), depression and cognitive status. The predictors included age, gender, marital status, education, number of chronic conditions, and depression. Descriptive and analytical statistical tests (univariate and multiple regression analysis) were used to analyze the data.

RESULTS

The majority of participants were married (63.9%) and women (59.3%). Based on the results of the multiple regression analysis, age (B=-0.04, P = 0.04), depression (B=-0.12, P = 0.04), and IADL (B = 0.46, P < 0.001) were significant predictors for functional status in terms of BADL. Also, marital status (B=-0.51, P = 0.05), numbers of chronic conditions (B=-0.61, P = 0.002), and BADL (B = 0.46, P < 0.001) were significant predictors for functional status in terms of IADL.

CONCLUSION

The findings support the predictive ability of age, marital status, number of chronic diseases, and depression for the functional status. Older adults with multiple chronic conditions who are older, single, depressed and with more chronic conditions number are more likely to have limitations in functional status. Therefore, nurses and other health care providers can benefit from the results of this study and identify and pay more attention to the high risk older adult population.

Urban-rural differences in associations among perceived stress, resilience and self-care in Chinese older adults with multiple chronic conditions

BACKGROUND

Social determinants of health (SDH) are mainly comprised of structural and intermediary domains. Emerging evidence suggests that the burden of multiple chronic conditions (MCCs) in older adults is exacerbated by structural determinants (e.g. low income and low education). However, less attention was paid to the intermediary determinants (i.e. material circumstances, psychosocial factors and behavioural factors) of MCCs.

OBJECTIVES

To investigate the associations among perceived stress, resilience and self-care in Chinese older adults with MCCs by comparing urban and rural groups.

METHODS

A convenience sample (125 and 115 participants from urban and rural settings, respectively) of Chinese older adults with MCCs was enrolled between January and April 2022. Hierarchical multiple regression analyses and propensity score weights were used to determine the associations among perceived stress, resilience and self-care.

RESULTS

Hypothesis 1 regarding the negative associations between perceived stress and self-care was fully supported in the rural group. However, for the urban group, the negative association was only supported for the relationship between MCCs-related perceived stress and self-care maintenance. Hypothesis 2 was fully supported regarding the positive associations between resilience and the three components of self-care in both groups, although the relationship between resilience and self-care monitoring was marginally significant in the urban group. Hypothesis 3 regarding the moderating effect of resilience was only supported in the relationship between general perceived stress and self-care monitoring in the rural group. After adding the propensity score weights, the moderating effect was no longer statistically significant in the rural group.

CONCLUSIONS

The urban-rural disparities in the Chinese context might largely be attributed to the complex interactions of the structural determinants and intermediary determinants. Findings can inform the development of culturally tailored interventions to promote self-care and reduce urban-rural disparities for Chinese older adults with MCCs.

IMPLICATIONS FOR PRACTICE

With the increasing number of older adults in China who are living with multiple chronic conditions and the call for effective interventions to improve their health outcomes, current findings can inform the development and implementation of nurse-led culturally tailored interventions to promote self-care and reduce urban-rural disparities for Chinese older adults with MCCs.

GDS score as screening tool to assess the risk of impact of chronic conditions and depression on quality of life in hospitalized elderly patients in internal medicine wards

Aging of population is characterized by multiple chronic conditions in the same individual. Health-related quality of life (HR-QOL) reflects the multidimensional impact of chronic disease on population and it is increasingly analysed as outcomes.The aim of this study was the evaluation of the predictors of quality of life among elderly patients hospitalized in internal medicine ward, investigating the effect of comorbidities on health-related quality of life.Data collected in this cross-sectional study were analysed. Socio-demographic, clinical characteristics, disease distribution and quality of life by the 12-Item Short Form Health Survey (SF-12) were evaluated.Of 240 inpatients, subjects with Barthel Index (BI)≤40 were 23.7%, 55% had a Geriatric Depression Scale (GDS)≥2. After categorizing mental component score (MCS) and physical component score (PCS) in five classes, we found that diabetics and patients with cancer were more frequent in the first class of MCS while patients with NYHA III-IV are significantly more frequent in the first class of PCS. When we classified patients according to GDS≥2 or < 2, subjects with GDS≥2 had BI and MCS significantly lower. In the multivariate analysis GDS score ≥2 was independently associated with first MCS class [16.32 (3.77-70.68)] while NYHA III-IV class and claudicatio intermittents were strong predictors of the worst PCS class [9.54 (1.97-47.40), 2.53 (1.16-5.49), respectively]. Liver disease was independently associated with GDS≥2 [5.26 (1.13-24.39)].Our study highlighted the impact of chronic diseases on health-related quality of life in elderly subjects hospitalized in an internal medicine ward pointing out the importance of taking into account patient's needs and perception and the setting up of a personalised health-care. Patients with diabetes and liver disease along with persons affected by cancer need psychological support to improve their quality of life. A GDS score ≥ 2 is a strong predictor of poor quality of life and should trigger an in-depth assessment of mental health in this kind of patients.

Combined Effects of Depression and Chronic Disease on the Risk of Mortality: The Korean Longitudinal Study of Aging (2006-2016)

BACKGROUND

The prevalence of depression is much higher in people with chronic disease than in the general population. Depression exacerbates existing physical conditions, resulting in a higher-than-expected death rate from the physical condition itself. In our aging society, the prevalence of multimorbid patients is expected to increase; the resulting mental problems, especially depression, should be considered. Using a large-scale cohort from the Korean Longitudinal Study of Aging (KLoSA), we analyzed the combined effects of depression and chronic disease on all-cause mortality.

METHODS

We analyzed 10-year (2006-2016) longitudinal data of 9,819 individuals who took part in the KLoSA, a nationwide survey of people aged 45-79 years. We examined the association between multimorbidity and depression using chi-square test and logistic regression. We used the Cox proportional hazard model to determine the combined effects of multimorbidity and depression on the all-cause mortality risk.

RESULTS

During the 10-year follow up, 1,574 people (16.0%) died. The hazard ratio associated with mild depression increased from 1.35 (95% confidence interval [CI], 1.05-1.73) for no chronic disease to 1.25 (95% CI, 0.98-1.60) for 1 chronic disease, and to 2.00 (95% CI, 1.58-2.52) for multimorbidity. The hazard ratio associated with severe depression increased from 1.73 (95% CI, 1.33-2.24) for no chronic disease, to 2.03 (95% CI, 1.60-2.57) for 1 chronic disease, and to 2.94 (95% CI, 2.37-3.65) for multimorbidity.

CONCLUSION

Patients with coexisting multimorbidity and depression are at an increased risk of all-cause mortality than those with chronic disease or depression alone.

Outcome Goals and Health Care Preferences of Older Adults With Multiple Chronic Conditions

IMPORTANCE

Older adults with multiple chronic conditions (MCCs) vary in their health outcome goals and the health care that they prefer to receive to achieve these goals.

OBJECTIVE

To describe the outcome goals and health care preferences of this population with MCCs.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study included participants in the Patient Priorities Care study who underwent health priorities identification from February 1, 2017, to August 31, 2018, in a primary care practice. Patients eligible to participate were 65 years or older, English speaking, and had at least 3 chronic conditions; in addition, they used at least 10 medications, saw at least 2 specialists, or had at least 2 emergency department visits or 1 hospitalization during the past year. Of 236 eligible patients, 163 (69%) agreed to participate in this study. Data were analyzed from August 1 to October 31, 2020.

EXPOSURES

Guided by facilitators, participants identified their core values, as many as 3 actionable and realistic outcome goals, health-related barriers to these goals, and as many as 3 helpful and 3 bothersome health care activities.

MAIN OUTCOMES AND MEASURES

Frequencies were ascertained for outcome goals and health care preferences. Preferences included health care activities (medications, health care visits, procedures, diagnostic tests, and self-management) reported as either helpful or bothersome.

RESULTS

Most of the 163 participants were White (158 [96.9%]) and women (109 [66.9%]), with a mean (SD) age of 77.6 (7.6) years. Of 459 goals, the most common encompassed meals and other activities with family and friends (111 [24.2%]), shopping (28 [6.1%]), and exercising (21 [4.6%]). Twenty individuals (12.3%) desired to live independently without specifying necessary activities. Of 312 barriers identified, the most common were pain (128 [41.0%]), fatigue (45 [14.4%]), unsteadiness (42 [13.5%]), and dyspnea (19 [6.1%]). Similar proportions of patients identified at least 1 medication that was helpful (130 [79.8%]) or bothersome (128 [78.5%]). Medications most commonly cited as helpful were pain medications, including nonopiods (36 of 55 users [65.5%]) and opioids (15 of 27 users [55.6%]); sleep medications (27 of 51 users [52.9%]); and respiratory inhalants (19 of 45 [42.2%]). Most often mentioned as bothersome were statins (25 of 97 users [25.8%]) and antidepressants (13 of 40 users [32.5%]). Thirty-two participants (19.6%) reported using too many medications. Health care visits were identified as helpful by 43 participants (26.4%); 15 (9.2%) reported too many visits. Procedures were named helpful by 38 participants (23.3%); 24 (14.7%) cited unwanted procedures. Among 48 participants with diabetes, monitoring of glucose levels was doable for 18 (37.5%) and too bothersome for 9 (18.8%).

CONCLUSIONS AND RELEVANCE

Participants identified realistic and actionable goals while varying in health care activities deemed helpful or bothersome. The goals and health care preferences of more diverse populations must be explored. Previous work suggests that clinicians can use this information in decision-making.

Managing Multimorbidity (Multiple Chronic Diseases) Amid COVID-19 Pandemic: A Community Based Study From Odisha, India

While most of the studies to date demonstrate the deleterious effect of multiple chronic diseases on COVID-19 risk and outcome, there is sparse information available on the effect of the pandemic on multimorbidity management, with no reports yet from India. We sought to explore the effect of COVID-19 pandemic on routine and emergency care for multimorbidity among community-dwelling adults in Odisha, India. A community-based cross-sectional study was undertaken pandemic lockdown, in Khurda district of Odisha, India. Around 600 individuals having at least one chronic disease residing in rural, urban residential and slums were interviewed using a specifically developed questionnaire MAQ COVID-19. The association of socio-demographic characteristics and multimorbidity with pandemic-related care challenges was examined by multiple logistic regression. Principal Component Analysis was employed to minimize the dimensionality of factors related to multimorbidity care. Multimorbidity was highly prevalent in younger age group (46-60 years) with cardio-metabolic clusters being dominant. Individuals with multimorbidity experienced significantly higher care challenges than those with single condition (AOR = 1.48, 95% CI = 1.01-2.05) with notable disruption in treatment and routine check-up. Most frequently cited concerns were-physician consultation (43%), diagnostic-services (26%), transport (33%), and mobility restrictions (21%). Multivariate analysis revealed older adults living alone in urban residence to have higher challenges than their rural counterparts. Patient activation for self-care, multimorbidity literacy, and technology-enabled tele-consultation could be explored as potential interventions. Future studies should qualitatively explore the challenges of physicians as well as garner an in-depth understanding of multimorbidity management in the vulnerable subgroups.

[Moral case deliberation in complex euthanasia requests]

Dealing with euthanasia requests can be a complex matter for a doctor. How to determine whether the due diligence criteria of the Dutch Euthanasia Act are met in cases that are not straightforward? We argue that moral case deliberation (MCD), methodically structured reflective discussions on concrete moral dilemmas, can provide support in dealing with complex euthanasia requests. In this article, we discuss a case that was talked about during a MCD (in particular the CURA method, where CURA stands for 'concentrating, postponing, reflecting and action') by a group of GPs and nurses who met in the context of a network for ambulatory palliative care.This was about an older patient with multiple chronic conditions who lost any prospects of quality of life.Among other things, it was examined whether requests could be 'well-considered' (one of the due diligence criteria) when the patients are in doubt as to when euthanasia should be carried out.The importance of recognising one's own emotions as a doctor and the quality of communication between patient and doctor were also considered.For that reason, we try to show that MCD can assist in making careful and well-considered decisions when determining a course of action in the case of complex euthanasia requests and can encourage collaborative learning processes.

[Accumulation of health problems as grounds for euthanasia]

BACKGROUND

The accumulation of health problems as grounds for euthanasia often poses a challenge for physicians. The distinction between the accumulation of health problems and a 'completed life' is sometimes hard to make. Suffering is subjective and the question is if and to what extent pronounced anticipatory suffering and detachment should be considered in the request for euthanasia.

CASE

A very old lady, who sets great store by propriety, requests euthanasia because she feels she will no longer be able to live an independent life. Her symptoms are related to a number of chronic degenerative disorders which have as yet not affected her functioning. Objectively, her case appears to be insufficiently severe. The physicians involved in her case differ in opinion until a new diagnosis resolves outstanding dilemmas.

CONCLUSION

Chronic symptoms and loss of function, a diminishing capacity, limited life perspective and the inevitability of and fear for pending care dependency can make life intolerable for the elderly individual. Careful consideration of the suffering and an empathetic approach are key to responding appropriately to a request for euthanasia.

Creating a Film to Teach Health Professions Students the Importance of Interprofessional Collaboration

Objective. To produce, implement, and evaluate the effectiveness of a film to develop the foundational knowledge and skills of health professions students and teach them the importance of interprofessional collaboration. Methods. An existing interprofessional case study about a Hispanic man suffering from multiple chronic health conditions and the impact his health had on his family served as the basis for the film. To ensure a high-quality production, faculty members partnered with a local theatre company to produce the film. Upon completion, the film was integrated into an annual interprofessional forum and evaluated by both students and faculty members in 2016, 2017, and 2018. Results. The 22-minute film, entitled Meet Fred Santiago: Improving Care Through Interprofessional Collaboration, was shown to 1921 students and 250 faculty members who participated in the interprofessional forum over the three years. Of these, 1858 students and 174 faculty members completed a program evaluation following the forum. The majority (>86%) of student and faculty respondents agreed or strongly agreed that the film presented a realistic view of the challenges faced by people with multiple chronic health problems. The majority of students (>85%) agreed or strongly agreed that the film helped them appreciate the breadth of issues confronting individuals with multiple chronic health problems. Conclusion. The film, Meet Fred Santiago, is an effective tool for introducing health professions students to the complex interrelationship of medical, psychological, and social issues experienced by individuals with chronic health conditions.

Cohort profile: The prospective study on Chinese elderly with multimorbidity in primary care in Hong Kong

PURPOSE

This is an ongoing prospective cohort aiming to examine the biopsychosocial health profiles and predictors of health outcomes of older patients with multimorbidity in primary care in Hong Kong.

PARTICIPANTS

From April 2016 to October 2017, 1077 patients aged 60+ years with at least two chronic diseases were recruited in four public primary care clinics in the New Territories East Region of Hong Kong.

FINDINGS TO DATE

After weighting, the patients had 4.1 (1.8) chronic conditions and 2.5 (1.9) medications on average; 37% forgot taking medication sometimes; 71% rated their health as fair or poor; 17% were frail; 73% reported one (21%) or two or more (52%) body pain areas; 62% were overweight/obese; 23% reported chewing difficulty, 18% reported incontinence; 36% had current stage 1/2 hypertension; 38% had handgrip strength below the cut-off; 10% screened positive in sarcopenia; 17% had mild or severer cognitive impairment; 17% had mild to severe depression; 16% had mild to severe anxiety; 50% had subthreshold to severe insomnia; 28% indicated being lonely; 12% needed help in at least one out of the five daily functions and the EuroQoL-5-Dimensions-5-Level index score was 0.81 (0.20) and its Visual Analogue Scale (VAS) score was 67.6 (14.6). In the past 12 months, 17% were hospitalised, 92% attended general outpatient clinics, 70% attended specialist outpatient clinics and 10% used elderly daycare centre services, the median out-of-pocket health cost was HK$1000 (US$150). Female and male patients showed significant differences in many biopsychosocial health aspects.

FUTURE PLANS

With assessments and clinical data, the cohort can be used for understanding longitudinal trajectories of biopsychosocial health profiles of Chinese older patients with multimorbidity in primary care. We are also initially planning cohort studies on factors associated with various health outcomes, as well as quality of life and healthcare use.

COHORT REGISTRATION NUMBER

ChiCTR-OIC-16008477.

Changes in Care- A Systematic Scoping Review of Transitions for Children with Medical Complexities

BACKGROUND

Children with medical complexity (CMC) and their parents are affected physically and mentally during transitions in care. Coordinated models of care show promise in improving health outcomes.

OBJECTIVE

The purpose of this scoping review was to examine research related to CMC and their parents and transitions in care. The aim was 3-fold: (1) to examine the extent, range, and nature of research activity related to the impact of transitions on physical and mental health for CMC and their parents; (2) to summarize and disseminate research findings for key knowledge users; and (3) to identify research gaps in the existing literature to inform future studies.

METHODS

Twenty-three sources were identified through database searches and five articles met the inclusion criteria of CMC (multi-organ involvement or technology-dependent) (or parents of CMC) transitioning from hospital to alternate levels of care where outcome measures were physical or mental health-related.

RESULTS

Numerical analysis revealed substantial variation in methodological approaches and outcome measures. Content analysis revealed two themes for parents of CMC during this transition: (1) emotional distress, and (2) high expectations; and three themes for CMC: (1) improved health, (2) changes in emotion, and (3) disrupted relationships.

CONCLUSION

The findings from this scoping review reveal for parents, transitions in care are fraught with emotional distress and high expectations; and for CMC there are improvements in quality of life and emotional health post- hospital to home transitions when collaborative models of care are available. This review serves as an early attempt to summarize the literature and demonstrate a need for further research.

Outcome preferences of older people with multiple chronic conditions and hypertension: a cross-sectional survey using best-worst scaling

BACKGROUND

Older people with hypertension and multiple chronic conditions (MCC) receive complex treatments and face challenging trade-offs. Patients' preferences for different health outcomes can impact multiple treatment decisions. Since evidence about outcome preferences is especially scarce among people with MCC our aim was to elicit preferences of people with MCC for outcomes related to hypertension, and to determine how these outcomes should be weighed when benefits and harms are assessed for patient-centered clinical practice guidelines and health economic assessments.

METHODS

We sent a best-worst scaling preference survey to a random sample identified from a primary care network of Kaiser Permanente (Colorado, USA). The sample included individuals age 60 or greater with hypertension and at least two other chronic conditions. We assessed average ranking of patient-important outcomes using conditional logit regression (stroke, heart attack, heart failure, dialysis, cognitive impairment, chronic kidney disease, acute kidney injury, fainting, injurious falls, low blood pressure with dizziness, treatment burden) and studied variation across individuals.

RESULTS

Of 450 invited participants, 217 (48%) completed the survey, and we excluded 10 respondents who had more than two missing choices, resulting in a final sample of 207 respondents. Participants ranked stroke as the most worrisome outcome and treatment burden as the least worrisome outcome (conditional logit parameters: 3.19 (standard error 0.09) for stroke, 0 for treatment burden). None of the outcomes were always chosen as the most or least worrisome by more than 25% of respondents, indicating that all outcomes were somewhat worrisome to respondents. Predefined subgroup analyses according to age, self-reported life-expectancy, degree of comorbidity, number of medications and antihypertensive treatment did not reveal meaningful differences.

CONCLUSIONS

Although some outcomes were more worrisome to patients than others, our results indicate that none of the outcomes should be disregarded for clinical practice guidelines and health economic assessments.

Vulnerability as practice in diagnosing multiple conditions

The paper contributes to contemporary understandings of vulnerability by expanding their scope with an understanding of vulnerability as generated through institutionalised practices. The argument draws on experiential accounts of navigating the practices of diagnosis by people living with multiple conditions of ill-health and disability. Vulnerability as a concept is used widely across different domains and conveys a multitude of meanings. Contemporary biomedicine, and its associated health systems and services, understands vulnerability mostly as inherent to particular physical and mental bodily conditions that put people at risk of ill-health or emotionally fragility. This may combine with a more epidemiological understanding of vulnerability as the experience of certain population groups subject to entrenched structural inequalities. Philosophers and feminists have argued that vulnerability is a universal experience of being human while political commentators have explored its potential as a resource for resistance and action. Diagnosis within medicine and psychiatry has been the subject of extensive social analysis, critique and activism. The paper draws on first-hand experiential accounts collected through face-to-face interviews with people living with multiple conditions about their experiences of diagnosis, mostly at the primary care level. We identify five aspects to diagnostic practice that are harmful and exacerbate the experience of vulnerability: temporal sequencing; diagnostic authority; medical specialisation; strategic symptom selection; medical isolation. However, these diagnostic practices are not best understood only in terms of the power asymmetries inherent to the medical consultation, but are embedded into the very institution of diagnosis. The paper thus proposes a combined approach to vulnerability that recognises it as a universal condition of humanity but one that becomes animated or amplified for some bodies, through their own inherent incapacities or the external structures of inequality, and through the practices of medicine as situated in particular times and places.

Multiple chronic conditions: the need for integrated secondary care

Current hospital-level care is "mostly disease-specific and monodisciplinary-oriented". These three case reports show different journeys that patients with multiple chronic conditions experienced in Dutch secondary outpatient care, and aim to demonstrate why an integrated care approach might be beneficial for this group of patients.

Challenges and strategies in patients' health priorities-aligned decision-making for older adults with multiple chronic conditions

OBJECTIVES

While patients' health priorities should inform healthcare, strategies for doing so are lacking for patients with multiple conditions. We describe challenges to, and strategies that support, patients' priorities-aligned decision-making.

DESIGN

Participant observation qualitative study.

SETTING

Primary care and cardiology practices in Connecticut.

PARTICIPANTS

Ten primary care clinicians, five cardiologists, and the Patient Priorities implementation team (four geriatricians, physician expert in clinician training, behavioral medicine expert). The patients discussed were ≥ 66 years with >3 chronic conditions and ≥10 medications or saw ≥ two specialists.

EXPOSURE

Following initial training and experience in providing Patient Priorities Care, the clinicians and Patient Priorities implementation team participated in 21 case-based, group discussions (10 face-to-face;11 telephonic). Using emergent learning (i.e. learning which arises from interactions among the participants), participants discussed challenges, posed solutions, and worked together to determine how to align care options with the health priorities of 35 patients participating in the Patient Priorities Care pilot.

MAIN OUTCOMES

Challenges to, and strategies for, aligning decision-making with patient's health priorities.

RESULTS

Categories of challenges discussed among participants included uncertainty, complexity, and multiplicity of problems and treatments; difficulty switching to patients' priorities as the focus of decision-making; and differing perspectives between patients and clinicians, and among clinicians. Strategies identified to support patient priorities-aligned decision-making included starting with one thing that matters most to each patient; conducting serial trials of starting, stopping, or continuing interventions; focusing on function (i.e. achieving patient's desired activities) rather than eliminating symptoms; basing communications, decision-making, and effectiveness on patients' priorities not solely on diseases; and negotiating shared decisions when there are differences in perspectives.

CONCLUSIONS

The discrete set of challenges encountered and the implementable strategies identified suggest that patient priorities-aligned decision-making in the care of patients with multiple chronic conditions is feasible, albeit complicated. Findings require replication in additional settings and determination of their effect on patient outcomes.

Depression and multimorbidity: Considering temporal characteristics of the associations between depression and multiple chronic diseases

OBJECTIVES

Depression frequently co-occurs with multiple chronic diseases in complex, costly, and dangerous patterns of multimorbidity. The field of health psychology may benefit from evaluating the temporal characteristics of depression's associations with common diseases, and from determining whether depression is a central connector in multimorbid disease clusters. The present review addresses these issues by focusing on 4 of the most prevalent diseases: hypertension, ischemic heart disease, arthritis, and diabetes.

METHOD

Study 1 assessed how prior chronic disease diagnoses were associated with current depression in a large, cross-sectional, population-based study. It assessed depression's centrality using network analysis accounting for disease prevalence. Study 2 presents a systematic scoping review evaluating the extent to which depression was prospectively associated with the onset of the 4 prevalent chronic diseases.

RESULTS

In Study 1 depression had the fourth highest betweenness centrality ranking of 26 network nodes and centrally connected many existing diseases and unhealthy behaviors. In Study 2 depression was associated with subsequent incidence of ischemic heart disease and diabetes across multiple meta-analyses. Insufficient information was available about depression's prospective associations with incident hypertension and arthritis.

CONCLUSIONS

Depression is central in patterns of multimorbidity and is associated with incident disease for several of the most common chronic diseases, justifying the focus on screening and treatment of depression in those at risk for developing chronic disease. Future research should investigate the mediating and moderating roles of health behaviors in the association between depression and the staggered emergence over time of clusters of multimorbid chronic diseases. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Experiences of community-dwelling older adults living with multiple chronic conditions: a qualitative study

OBJECTIVES

The aim of the study was to understand the experiences of living with multiple chronic conditions (MCC) from the perspective of community-living older adults with MCC.

DESIGN

A qualitative study using an interpretive description approach.

SETTING

Participants were recruited from southern Ontario, Canada.

PARTICIPANTS

21 community-living, older adults (≥65 years) with an average of 7.4 chronic conditions including one of diabetes, dementia or stroke.

METHODS

Data were collected through digitally-recorded, in-depth, semi-structured in-person interviews. Interview transcripts were analysed and coded using Thorne's interpretive description approach.

RESULTS

Five themes were identified representing older adults' experiences of living with MCC: (a) trying to stay healthy while living with MCC, (b) depending on family caregivers for support with just about everything, (c) paying the high costs of living with MCC, (d) making healthcare decisions by proxy and (e) receiving healthcare services that do not address the complex needs of persons living with MCC.

CONCLUSIONS

The experience of living with MCC in the community was complex and multi-faceted. The need for a person-centred and family-centred approach to care in the community, which includes the coordination of health and social services that are tailored to the needs of older adults and their informal caregivers, was underscored. Such an approach would facilitate improved information-sharing and discussion of care management options between health professionals and their patients, enable older adults with MCC to actively engage in priority-setting and decision-making and may result in improved health and quality of life for older adults with MCC.

Multimorbidity, eHealth and implications for equity: a cross-sectional survey of patient perspectives on eHealth

OBJECTIVE

There is increasing awareness of the burden of medical care experienced by those with multimorbidity. There is also increasing interest and activity in engaging patients with chronic disease in technology-based health-related activities ('eHealth') in family practice. Little is known about patients' access to, and interest in eHealth, in particular those with a higher burden of care associated with multimorbidity. We examined access and attitudes towards eHealth among patients attending family medicine clinics with a focus on older adults and those with polypharmacy as a marker for multimorbidity.

DESIGN

Cross-sectional survey of consecutive adult patients attending consultations with family physicians in the McMaster University Sentinel and Information Collaboration practice-based research network. We used univariate and multivariate analyses for quantitative data, and thematic analysis for free text responses.

SETTING

Primary care clinics.

PARTICIPANTS

693 patients participated (response rate 70%).

INCLUSION CRITERIA

Attending primary care clinic.

EXCLUSIONS

Too ill to complete survey, cannot speak English.

RESULTS

The majority of participants reported access to the internet at home, although this decreased with age. Participants 70 years and older were less comfortable using the internet compared with participants under 70. Univariate analyses showed age, multimorbidity, home internet access, comfort using the internet, privacy concerns and self-rated health all predicted significantly less interest in eHealth. In the multivariate analysis, home internet access and multimorbidity were significant predictors of disinterest in eHealth. Privacy and loss of relational connection were themes in the qualitative analysis.

CONCLUSION

There is a significant negative association between multimorbidity and interest in eHealth. This is independent of age, computer use and comfort with using the internet. These findings have important implications, particularly the potential to further increase health inequity.

Secondary care experiences of patients with multiple chronic conditions

BACKGROUND

This study aimed to investigate patients' experiences, beliefs and understandings of the current secondary care of patients with multiple chronic conditions (MCC) in the Netherlands.

METHODS

A qualitative, interpretative description design was used. We conducted semi-structured, in-depth interviews with patients with MCC, who visited at least two physicians in Gelre Hospitals for at least two appointments in the previous year. After eight interviews data saturation was achieved.

RESULTS

Being a patient with MCC in the hospital can be complex and keeping an overview required effort, according to the participants. Most participants would appreciate more coordination and communication. However, the exact needs seemed to differ. The multiple visits transformed them into experienced patients: based on their experiences and observations they developed strategies to sustain themselves in the hospital. Different types of communication (an important, overarching theme) evoked specific feelings and expectations that were important for the patients' care experiences as well.

CONCLUSION

An overview of patient care seems an essential element for a more coordinated, individualised approach to care. Future research might focus on ways to engage both healthcare professionals and patients in the improvement of care. It could aim to find ways to create an overview and coordination, and define responsibilities, but also to clarify which groups of patients need assistance. It might also investigate the effect of good and clear communication on reducing obstacles that patients perceive when dealing with healthcare situations. Overall, also in the future, patients' care experiences could play an important role in determining the direction of new interventions.

Exploring the role of regulation and the care of older people with depression living in long-term care? A systematic scoping review protocol

INTRODUCTION

This systematic scoping review will explore the role of regulation on the care of older people living with depression in long-term care. Depression presents a significant burden to older people living in long-term care. Regulation in the long-term care sector has increased, but there are still concerns about quality of care in the sector.

METHODS AND ANALYSIS

Using Arksey and O'Malley's scoping review methodology as a guide, our scoping review will search several databases: Embase; MEDLINE (using the OVID platform); Psych info; Ageline; and CINAHL, alongside the grey literature. An expert librarian has assisted the research team, using the Peer Review of Electronic Search Strategies, to assess the search strategy. The research team has formulated search strategies and two reviewers will independently screen studies for final study selection. We will summarise extracted data in tabular format; use a narrative format to describe their relevance; and finally, identify knowledge gaps and topics for future research.

ETHICS AND DISSEMINATION

This scoping review will outline the scope of the existing literature related to the influence of regulation on the care of older people living with depression in long-term care. The scoping review findings will be disseminated through publication in a peer-reviewed journal. The findings will be useful to policy-makers, managers and clinicians working in the long-term care sector.

Comparative Effectiveness of Coalitions Versus Technical Assistance for Depression Quality Improvement in Persons with Multiple Chronic Conditions

SIGNIFICANCE

Prior research suggests that Community Engagement and Planning (CEP) for coalition support compared with Resources for Services (RS) for program technical assistance to implement depression quality improvement programs improves 6- and 12-month client mental-health related quality of life (MHRQL); however, effects for clients with multiple chronic medical conditions (MCC) are unknown.

OBJECTIVE

To explore effectiveness of CEP vs RS in MCC and non-MCC subgroups.

DESIGN

Secondary analyses of a cluster-randomized trial.

SETTING

93 health care and community-based programs in two neighborhoods.

PARTICIPANTS

Of 4,440 clients screened, 1,322 depressed (Patient Health Questionnaire, PHQ8) provided contact information, 1,246 enrolled and 1,018 (548 with ≥3 MCC) completed baseline, 6- or 12-month surveys.

INTERVENTION

CEP or RS for implementing depression quality improvement programs.

OUTCOMES AND ANALYSES

Primary: depression (PHQ9 <10), poor MHRQL (Short Form Health Survey, SF-12<40); Secondary: mental wellness, good physical health, behavioral health hospitalization, chronic homelessness risk, work/workloss days, services use at 6 and 12 months. End-point regressions were used to estimate intervention effects on outcomes for subgroups with ≥3 MCC, non-MCC, and intervention-by-MCC interactions (exploratory).

RESULTS

Among MCC clients at 6 months, CEP vs RS lowered likelihoods of depression and poor MHRQL; increased likelihood of mental wellness; reduced work-loss days among employed and likelihoods of ≥4 behavioral-health hospitalization nights and chronic homelessness risk, while increasing faith-based and park community center depression services; and at 12 months, likelihood of good physical health and park community center depression services use (each P<.05). There were no significant interactions or primary outcome effects for non-MCC.

CONCLUSIONS

CEP was more effective than RS in improving 6-month primary outcomes among depressed MCC clients, without significant interactions.

Physical Training in a Medical Fitness Room for Patients with Chronic Diseases: Functional and Metabolic Outcomes

BACKGROUND

Physical inactivity is a pivotal factor in the development and progression of various chronic diseases. However, most fitness facilities exclude unhealthy individuals. Therefore, an exercise program that admits such patients is imperative.

OBJECTIVES

To evaluate the effectiveness of a fitness facility that admits adult subjects with multiple chronic diseases.

METHODS

We conducted a retrospective screening of patient records from the Medical Fitness Facility at Meir Medical Center, Israel. Intake of subjects was done by a multidisciplinary team. For each individual, personalized diet and exercise plans were developed and patients attended the facility twice a week. Each participant was evaluated at enrolment and after 4 months for well-being, metabolic parameters, exercise capacity, and laboratory blood tests.

RESULTS

A total of 838 individuals were enrolled, mean age 57 years. Their medical conditions included dyslipidemia (48.8%), hypertension (37.6%), and diabetes mellitus (24.9%), followed by musculoskeletal problems (arthropathy 19%, lower back pain 16.1%) and ischemic heart disease (13.4%). Less common diagnoses were vascular diseases, pulmonary diseases, and malignancy. Only 40.5% of participants adhered to the regimen with advanced age being the best predictor for adherence. At the follow-up visit, body mass index was lower (31.2 vs. 30.2 kg/m2, P <0.0001), exercise capacity increased (measured as maximal MET; 7.1 vs. 8.1, P < 0.0001), and well-being improved (measured by Short Form Survey [SF-36]; 69.3 vs. 76.0, P <0.0001).

CONCLUSIONS

We show that a fitness program for patients with multiple chronic diseases is feasible and effective in improving prognostic parameters, albeit significantly challenged by adherence limitations.

Identifying and understanding the health and social care needs of older adults with multiple chronic conditions and their caregivers: a protocol for a scoping review

INTRODUCTION

People are living longer; however, they are not necessarily experiencing good health and well-being as they age. Many older adults live with multiple chronic conditions (MCC), and complex health issues, which adversely affect their day-to-day functioning and overall quality of life. As a result, they frequently rely on the support of friend and/or family caregivers. Caregivers of older adults with MCC often face challenges to their own well-being and also require support. Currently, not enough is known about the health and social care needs of older adults with MCC and the needs of their caregivers or how best to identify and meet these needs. This study will examine and synthesise the literature on the needs of older adults with MCC and those of their caregivers, and identify gaps in evidence and directions for further research.

METHODS AND ANALYSIS

We will conduct a scoping review of the peer-reviewed and grey literature using the updated Arksey and O'Malley framework. The literature will be identified using a multidatabase and grey literature search strategy developed by a health sciences librarian. Papers, reports and other materials addressing the health and social care needs of older adults and their friend/family caregivers will be included. Search results will be screened, independently, by two reviewers, and data will be abstracted from included literature and charted in duplicate.

ETHICS AND DISSEMINATION

This scoping review does not require ethics approval. We anticipate that study findings will inform novel strategies for identifying and ascertaining the health and social care needs of older adults living with MCC and those of their caregivers. Working with knowledge-user members of our team, we will prepare materials and presentations to disseminate findings to relevant stakeholder and end-user groups at local, national and international levels. We will also publish our findings in a peer-reviewed journal.

Understanding What Is Most Important to Individuals with Multiple Chronic Conditions: A Qualitative Study of Patients' Perspectives

BACKGROUND

To improve care for individuals living with multiple chronic conditions, patients and providers must align care planning with what is most important to patients in their daily lives. We have a limited understanding of how to effectively encourage communication about patients' personal values during clinical care.

OBJECTIVE

To identify what patients with multiple chronic conditions describe as most important to their well-being and health.

DESIGN

We interviewed individuals with multiple chronic conditions in their homes and analyzed results qualitatively, guided by grounded theory.

PARTICIPANTS

A total of 31 patients (mean age 68.7 years) participated in the study, 19 of which included the participation of family members. Participants were from Kaiser Permanente Washington, an integrated health care system in Washington state.

APPROACH

Qualitative analysis of home visits, which consisted of semi-structured interviews aided by photo elicitation.

KEY RESULTS

Analysis revealed six domains of what patients described as most important for their well-being and health: principles, relationships, emotions, activities, abilities, and possessions. Personal values were interrelated and rarely expressed as individual values in isolation.

CONCLUSIONS

The domains describe the range and types of personal values multimorbid older adults deem important to well-being and health. Understanding patients' personal values across these domains may be useful for providers when developing, sharing, and following up on care plans.

Beyond Hospital Discharge Mechanics: Managing the Discharge Paradox and Bridging the Care Chasm

Hospital discharge processes are complex and confusing, and can detrimentally affect patients, families, and providers. This qualitative study investigated pediatric hospital discharge experiences from the perspectives of parents of children with acute and chronic health conditions, primary care providers, and hospitalists. Focus groups and interviews with parents, primary care providers, and hospitalists were used to explore discharge experiences and ideas for improvement offered by participants. Using an iterative approach to analyze data resulted in five major themes for discharge experiences: (a) discharge problems, (b) teamwork, (c) ideal discharge, (d) care chasm, and (e) discharge paradox. The first three themes concern practical issues, whereas the last two themes reflect negative emotional experiences as well as practical problems encountered in the discharge process. Improvements in communication were viewed as a primary strategy for improving the discharge process for better outcomes for patients, their families, and providers.

Use of polypharmacy and herbal medication on quality of life in elderly patients at Okmeydani hospital's polyclinics in Istanbul, Turkey

OBJECTIVE

To determine what should be done as a preventive medicine physician by analysing the effect of polypharmacy and herbal treatment.

METHODS

This survey-based, cross-sectional study was carried out at Istanbul Okmeydani Training and Research Hospital, Istanbul, Turkey, from February to May 2015, and comprised patients using two or more medicines at full strength for at least 240 days. The patients were classified into two groups. Group A comprised those who were using less than 4 medications (at least 2), while group B comprised patients using more than 4 medications. The short version of World Health Organisation's quality-of-life questionnaire was applied. SPSS 22 was used for data analysis.

RESULTS

Of the 350 participants, 106(30.3%) were receiving herbal treatment while 244(69.7%) had no such treatment. Group B patients had meaningfully lower scores for body, spiritual, social and external environment (p=0.001). Moreover, the patients having no herbal or supportive treatment scored significantly higher in the physical, spiritual, social relations and external environment (p=0.001). In group A, patients receiving no herbal treatment scored meaningfully higher in all fields, including physical (p=0.009), social relations (p=0.043) and external environment (p=0.001).

CONCLUSIONS

Old age, living alone, level of education, having a regular monthly income, the number of drugs used, chronic diseases and herbal treatments affected the life quality.

The ACHRU-CPP versus usual care for older adults with type-2 diabetes and multiple chronic conditions and their family caregivers: study protocol for a randomized controlled trial

BACKGROUND

Many community-based self-management programs have been developed for older adults with type-2 diabetes mellitus (T2DM), bolstered by evidence from randomized controlled trials (RCTs) that T2DM can be prevented and managed through lifestyle modifications. However, the evidence for their effectiveness is contradictory and weakened by reliance on single-group designs and/or small samples. Additionally, older adults with multiple chronic conditions (MCC) are often excluded because of recruiting and retention challenges. This paper presents a protocol for a two-armed, multisite, pragmatic, mixed-methods RCT examining the effectiveness and implementation of the Aging, Community and Health Research Unit-Community Partnership Program (ACHRU-CPP), a new 6-month interprofessional, nurse-led program to promote self-management in older adults (aged 65 years or older) with T2DM and MCC and support their caregivers (including family and friends).

METHODS/DESIGN

The study will enroll 160 participants in two Canadian provinces, Ontario and Alberta. Participants will be randomly assigned to the control (usual care) or program study arm. The program will be delivered by registered nurses (RNs) and registered dietitians (RDs) from participating diabetes education centers (Ontario) or primary care networks (Alberta) and program coordinators from partnering community-based organizations. The 6-month program includes three in-home visits, monthly group sessions, monthly team meetings for providers, and nurse-led care coordination. The primary outcome is the change in physical functioning as measured by the Physical Component Summary (PCS-12) score from the short form-12v2 health survey (SF-12). Secondary client outcomes include changes in mental functioning, depressive symptoms, anxiety, and self-efficacy. Caregiver outcomes include health-related quality of life and depressive symptoms. The study includes a comparison of health care service costs for the intervention and control groups, and a subgroup analysis to determine which clients benefit the most from the program. Descriptive and qualitative data will be collected to examine implementation of the program and effects on interprofessional/team collaboration.

DISCUSSION

This study will provide evidence of the effectiveness of a community-based self-management program for a complex target population. By studying both implementation and effectiveness, we hope to improve the uptake of the program within the existing community-based structures, and reduce the research-to-practice gap.

TRIAL REGISTRATION

ClinicalTrials.gov, Identifier: NCT02158741 . Registered on 3 June 2014.

Best Practice in Provider/Parent Interaction

In this 3-year prospective grounded theory study in three pediatric settings, we aimed to develop a conceptualization of best practice health care providers (BPHCPs) in interaction with parents of children with complex, chronic, life-threatening conditions. Analysis of semistructured interviews with 34 parents and 80 health care professionals (HCPs) and 88 observation periods of HCP/parent interactions indicated that BPHCPs shared a broad worldview; values of equity, family-centered care, and integrity; and a commitment to authentic engagement. BPHCPs engaged in direct care activities, in connecting behaviors, and in exquisitely attuning to particularities of the situation in the moment, resulting in positive outcomes for parents and HCPs. By focusing on what HCPs do well, findings showed that not only is it possible for HCPs to practice in this way, but those who do so are also recognized as being the best at what they do. We provide recommendations for practice and initial and ongoing professional education.

Managing multiple chronic conditions in the community: a Canadian qualitative study of the experiences of older adults, family caregivers and healthcare providers

BACKGROUND

The prevalence of multiple chronic conditions (MCC) among older persons is increasing worldwide and is associated with poor health status and high rates of healthcare utilization and costs. Current health and social services are not addressing the complex needs of this group or their family caregivers. A better understanding of the experience of MCC from multiple perspectives is needed to improve the approach to care for this vulnerable group. However, the experience of MCC has not been explored with a broad sample of community-living older adults, family caregivers and healthcare providers. The purpose of this study was to explore the experience of managing MCC in the community from the perspectives of older adults with MCC, family caregivers and healthcare providers working in a variety of settings.

METHODS

Using Thorne's interpretive description approach, semi-structured interviews (n = 130) were conducted in two Canadian provinces with 41 community-living older adults (aged 65 years and older) with three or more chronic conditions, 47 family caregivers (aged 18 years and older), and 42 healthcare providers working in various community settings. Healthcare providers represented various disciplines and settings. Interview transcripts were analyzed using Thorne's interpretive description approach.

RESULTS

Participants described the experience of managing MCC as: (a) overwhelming, draining and complicated, (b) organizing pills and appointments, (c) being split into pieces, (d) doing what the doctor says, (e) relying on family and friends, and (f) having difficulty getting outside help. These themes resonated with the emotional impact of MCC for all three groups of participants and the heavy reliance on family caregivers to support care in the home.

CONCLUSIONS

The experience of managing MCC in the community was one of high complexity, where there was a large gap between the needs of older adults and caregivers and the ability of health and social care systems to meet those needs. Healthcare for MCC was experienced as piecemeal and fragmented with little focus on the person and family as a whole. These findings provide a foundation for the design of care processes to more optimally address the needs-service gap that is integral to the experience of managing MCC.

"I Need my Own Place to get Better": Patient Perspectives on the Role of Housing in Potentially Preventable Hospitalizations

OBJECTIVE

To analyze patient perspectives on the role of housing in their potentially preventable hospitalization.

METHODS

Individuals admitted with cardiovascular-or diabetes-related diagnoses (n = 90) in a major medical center in Hawai'i completed an in-person interview eliciting patient perspectives on key factors leading to hospitalization. Using the framework approach, two independent coders identified themes. This study focused on housing-related findings.

RESULTS

Overall, 23% of participants reported housing as a precipitating factor to their hospitalization, including 12 with no regular place to stay. Four housing-related themes emerged: challenges meeting basic needs, complex chronic care management difficulties, stigma and relationship with provider, and stress and other mental health issues.

DISCUSSION

Almost 25% of patients identified housing as a key factor to their hospital stay. Patient-reported themes highlight specific mechanisms by which housing challenges may lead to hospitalization. Addressing housing issues could help reduce the number and associated cost burden of preventable hospitalizations.

Diverse Cumulative Impact of Chronic Diseases on Physical Health-Related Quality of Life: Implications for a Measure of Multimorbidity

Debate continues on how to measure and weight diseases in multimorbidity. We quantified the association of a broad range of chronic diseases with physical health-related qualify of life and used these weights to develop and validate a multimorbidity weighted index (MWI). Community-dwelling adults in 3 national, prospective studies-the Nurses' Health Study (n = 121,701), Nurses' Health Study II (n = 116,686), and Health Professionals Follow-up Study (n = 51,529)-reported physician-diagnosed diseases and completed the Short Form 36 physical functioning (PF) scale over multiple survey cycles between 1992 and 2008. Mixed models were used to obtain regression coefficients for the impact of 98 morbid conditions on PF. The MWI was formed by weighting conditions by these coefficients and was validated through bootstrapping. The final sample included 612,592 observations from 216,890 participants (PF mean score = 46.5 (standard deviation, 11)). The association between diseases and PF varied severalfold (median, -1.4; range, -10.6 to 0.8). End-stage organ diseases were associated with the greatest reduction in PF. The mean MWI score was 4.8 (median, 3.7; range, 0-53), and the mean number of comorbid conditions was 3.3 (median, 2.8; range, 0-34). This validated MWI weights diseases by severity using PF, a patient-centered outcome. These results suggest that simple disease count is unlikely to capture the full impact of multimorbidity on health-related quality of life, and that the MWI is feasible and readily implemented.

The Association Between Perceived Stress and Mortality Among People With Multimorbidity: A Prospective Population-Based Cohort Study

Multimorbidity is common and is associated with poor mental health and high mortality. Nevertheless, no studies have evaluated whether mental health may affect the survival of people with multimorbidity. We investigated the association between perceived stress and mortality in people with multimorbidity by following a population-based cohort of 118,410 participants from the Danish National Health Survey 2010 for up to 4 years. Information on perceived stress and lifestyle was obtained from the survey. We assessed multimorbidity using nationwide register data on 39 conditions and identified 4,229 deaths for the 453,648 person-years at risk. Mortality rates rose with increasing levels of stress in a dose-response relationship (P-trend < 0.0001), independently of multimorbidity status. Mortality hazard ratios (highest stress quintile vs. lowest) were 1.51 (95% confidence interval (CI): 1.25, 1.84) among persons without multimorbidity, 1.39 (95% CI: 1.18, 1.64) among those with 2 or 3 conditions, and 1.43 (95% CI: 1.18, 1.73) among those with 4 or more conditions, when adjusted for disease severities, lifestyle, and socioeconomic status. The numbers of excess deaths associated with high stress were 69 among persons without multimorbidity, 128 among those with 2 or 3 conditions, and 255 among those with 4 or more conditions. Our findings suggested that perceived stress contributes significantly to higher mortality rates in a dose-response pattern, and more stress-associated deaths occurred in people with multimorbidity.

Association among change in medical costs, level of comorbidity, and change in adherence behavior

OBJECTIVES

Interventions to improve medication adherence are effective, but resource intensive. Interventions must be targeted to those who will potentially benefit most. We examined what heterogeneity exists in the value of adherence based on levels of comorbidity, and the changes in spending on medical services that followed changes in adherence behavior.

STUDY DESIGN

Retrospective cohort study examining medical spending for 2 years (April 1, 2011, to March 31, 2013) in commercial insurance beneficiaries.

METHODS

Multivariable linear modeling was used to adjust for differences in patient characteristics. Analyses were performed at the patient/condition level in 2 cohorts: adherent at baseline and nonadherent at baseline.

RESULTS

We evaluated 857,041 patients, representing 1,264,797 patient therapies consisting of 40% high cholesterol, 48% hypertension, and 12% diabetes. Among those with 3 or more conditions, annual savings associated with becoming adherent were $5341, $4423, and $2081 for patients with at least diabetes, hypertension, and high cholesterol, respectively. The increased costs for patients in this group who became nonadherent were $4653, $7946, and $4008, respectively. Depending on the condition and the direction of behavior change, savings were 2 to 7 times greater than the value for individuals with fewer than 3 conditions. In most cases, the value of preventing nonadherence (ie, persistence) was greater than the value of moving people who are nonadherent to an adherent state.

CONCLUSIONS

There is important heterogeneity in the impact of medication adherence on medical spending. Clinicians and policy makers should consider this when promoting the change of adherence behavior.

Health Self-Efficacy Among Populations with Multiple Chronic Conditions: the Value of Patient-Centered Communication

Introduction

Using cross-sectional survey data, we assessed the association between chronic illness burden and health-related self-efficacy, evaluating whether patient-centered communication is associated with self-efficacy and if that relationship varies by chronic illness burden.

Methods

Data were from the Health Information National Trends Survey, a cross-sectional survey of the US adult population collected in 2012–2013 (n = 3630). Health-related self-efficacy was measured with the item: “Overall, how confident are you about your ability to take good care of your health?” and the prevalence of six chronic conditions and depression/anxiety was assessed. Patient-centered communication was measured as the frequency with which respondents perceived their healthcare providers allowed them to ask questions, gave attention to their emotions, involved them in decisions, made sure they understood how to take care of their health, helped them to deal with uncertainty, and if they felt they could rely on their healthcare providers to take care of their healthcare needs.

Results

Health-related self-efficacy was significantly lower among individuals with greater illness burden. In adjusted analysis, individuals who experienced more positive patient-centered communication reported higher levels of self-efficacy (β = 0.26, P < 0.0001); this association was strongest among those with greater illness burden.

Conclusion

Higher levels of self-efficacy were observed among patients reporting more positive patient-centered communication; the observed association was stronger among those with greater chronic illness burden.

Electronic supplementary material

The online version of this article (doi:10.1007/s12325-016-0369-7) contains supplementary material, which is available to authorized users.

Multiple Chronic Conditions and Psychosocial Limitations in Patients Hospitalized with an Acute Coronary Syndrome

BACKGROUND

As adults live longer, multiple chronic conditions have become more prevalent over the past several decades. We describe the prevalence of, and patient characteristics associated with, cardiac- and non-cardiac-related multimorbidities in patients discharged from the hospital after an acute coronary syndrome.

METHODS

We studied 2174 patients discharged from the hospital after an acute coronary syndrome at 6 medical centers in Massachusetts and Georgia between April 2011 and May 2013. Hospital medical records yielded clinical information including presence of eight cardiac-related and eight non-cardiac-related morbidities on admission. We assessed multiple psychosocial characteristics during the index hospitalization using standardized in-person instruments.

RESULTS

The mean age of the study sample was 61 years, 67% were men, and 81% were non-Hispanic whites. The most common cardiac-related morbidities were hypertension, hyperlipidemia, and diabetes (76%, 69%, and 31%, respectively). Arthritis, chronic pulmonary disease, and depression (20%, 18%, and 13%, respectively) were the most common noncardiac morbidities. Patients with ≥4 morbidities (37% of the population) were slightly older and more frequently female than those with 0-1 morbidity; they were also heavier and more likely to be cognitively impaired (26% vs 12%), have symptoms of moderate/severe depression (31% vs 15%), high perceived stress (48% vs 32%), a limited social network (22% vs 15%), low health literacy (42% vs 31%), and low health numeracy (54% vs 42%).

CONCLUSION

Multimorbidity, highly prevalent in patients hospitalized with an acute coronary syndrome, is strongly associated with indices of psychosocial deprivation. This emphasizes the challenge of caring for these patients, which extends well beyond acute coronary syndrome management.

Multiple Chronic Conditions, Spouse's Depressive Symptoms, and Gender within Marriage

Multiple chronic conditions (i.e., multimorbidity) increase a person's depressive symptoms more than having one chronic condition. Little is known regarding whether multimorbidity similarly increases the depressive symptoms of one's spouse and whether this depends on type of condition, gender, or both spouses' health status. Analysis of multiple waves of the Health and Retirement Study reveals husband's number of chronic conditions is positively related to wife's depressive symptoms when both spouses are chronically ill. The association between wife's chronic conditions and husband's depressive symptoms is weaker and less robust. Type of chronic condition also matters but which type depends on the gender and health status of both spouses. By highlighting key contexts where chronic conditions are connected to spousal depressive symptoms, this study identifies areas of vulnerability and urges researchers and clinicians to consider multimorbidity when designing and implementing interventions, along with gender, both spouses' chronic conditions, and condition type.

Dual, Yet Dueling Illnesses: Multiple Chronic Illness Experience at Midlife

The prevalence of multiple chronic illnesses is increasing dramatically, especially among those in middle adulthood, yet much prior research has focused on the experience of multiple morbidity among older adults. We examined the online illness narratives (blogs) of 10 men and women aged 36 to 59 to better understand the experience of living with multiple chronic illnesses at midlife. Multiple morbidity presents distinct challenges to those at midlife: (a) diagnosis and management of multiple illnesses, (b) need for information, (c) identity dilemmas and threats to self-image, and (d) stigma and social rejection. Relinquishing the work identity was especially difficult for participants because it threatened to foreshorten middle adulthood and push them prematurely into late adulthood. Participants used their blogs to revise their identities, alleviate isolation, and inform and guide others.