Mental health and risk of death and hospitalization in COVID-19 patients. Results from a large-scale population-based study in Spain

The COVID-19 pandemic has created unprecedented challenges for health care systems globally. This study aimed to explore the presence of mental illness in a Spanish cohort of COVID-19-infected population and to evaluate the association between the presence of specific mental health conditions and the risk of death and hospitalization. This is a retrospective cohort study including all individuals with confirmed infection by SARS-CoV-2 from the PRECOVID (Prediction in COVID-19) Study (Aragon, Spain). Mental health illness was defined as the presence of schizophrenia and other psychotic disorders, anxiety, cognitive disorders, depression and mood disorders, substance abuse, and personality and eating disorders. Multivariable logistic regression models were used to examine the likelihood of 30-day all-cause mortality and COVID-19 related hospitalization based on baseline demographic and clinical variables, including the presence of specific mental conditions, by gender. We included 144,957 individuals with confirmed COVID-19 from the PRECOVID Study (Aragon, Spain). The most frequent diagnosis in this cohort was anxiety. However, some differences were observed by sex: substance abuse, personality disorders and schizophrenia were more frequently diagnosed in men, while eating disorders, depression and mood, anxiety and cognitive disorders were more common among women. The presence of mental illness, specifically schizophrenia spectrum and cognitive disorders in men, and depression and mood disorders, substance abuse, anxiety and cognitive and personality disorders in women, increased the risk of mortality or hospitalization after COVID-19, in addition to other well-known risk factors such as age, morbidity and treatment burden. Identifying vulnerable patient profiles at risk of serious outcomes after COVID-19 based on their mental health status will be crucial to improve their access to the healthcare system and the establishment of public health prevention measures for future outbreaks.

Multimorbidity of Psoriasis: A Large-Scale Population Study of Its Associated Comorbidities

INTRODUCTION

Psoriasis is a chronic disease of the skin with a prevalence of 2% in the general population. The high prevalence of psoriasis has prompted the study of its comorbidities in recent decades. We designed a study to determine the prevalence of psoriasis in a large-scale, population-based cohort, to exhaustively describe its comorbidities, and to analyze which diseases are associated with psoriasis.

METHODS

Retrospective, observational study based on the clinical information contained in the electronic health records of the individuals in the EpiChron Cohort with a diagnosis of psoriasis (31,178 individuals) in 2019. We used logistic regression models and calculated the likelihood of the occurrence of each comorbidity based on the presence of psoriasis (p-value < 0.05).

RESULTS

The prevalence of psoriasis was 2.84%, and it was more prevalent in men (3.31% vs. 2.43%). The most frequent chronic comorbidities were disorders of lipid metabolism (35.87%), hypertension (35.50%), and other nutritional-endocrine-metabolic disorders (21.79%). The conditions most associated with psoriasis were (odds ratio; 95% confidence interval) tuberculosis (2.36; 1.24-4.49), cystic fibrosis (2.15; 1.25-3.69), amongst others. We did not find a significant association between psoriasis and hypertension or neoplasms (0.90; 0.86-0.95).

CONCLUSIONS

This study revealed significant associations between psoriasis and cardiac, psychological, and musculoskeletal comorbidities.

Multimorbidity patterns in older persons and their association with self-reported quality of life and limitations in activities of daily living

BACKGROUND

As populations age, multimorbidity (the presence of two or more chronic morbidities) is increasingly more common. These evolving demographics demand further research into the identification of morbidity patterns in different settings as well as the longitudinal effects of these patterns.

METHODS

Prospectively collected data on 12,755 older persons aged 65+ years were derived from The Older Persons and Informal Caregivers Survey Minimum DataSet (TOPICS-MDS, www.topics-mds.eu). Latent class analyses were performed to identify unobserved relationship patterns between morbidities in older persons. Using linear mixed models, the average difference in health-related quality of life (EQ-5D) and general quality of life scores (Cantril's Self Anchoring Ladder) as well as limitations in Activities of Daily Living and Instrumental Activities of Daily Living (ADL/IADL) were examined over a 12-month period.

RESULTS

Five multimorbidity patterns were identified: sensory (n = 3882), cardio-metabolic (n = 2627), mental health (n = 920), osteo-articular (n = 4486), and system decline (n = 840). Relative to older persons in the sensory group, multimorbidity patterns did not have a strong effect on health-related quality of life, general quality of life or ADL/IADLs over a one-year period.

CONCLUSIONS

The observed multimorbidity patterns are similar to others based on different methodologies and study populations. When examining the effect of such patterns on quality of life, the EQ-5D and Cantril's Ladder may be insufficient outcome measures. Further investigations into the prognostic value of morbidity patterns would be of benefit.

Multimorbidity, social determinants and intersectionality in chronic patients. Results from the EpiChron Cohort

Background

Multimorbidity is influenced in an interconnected way, both in extent and nature, by the social determinants of health. We aimed at implementing an intersectional approach to analyse the association of multimorbidity with five important axes of social inequality (i.e. gender, age, ethnicity, residence area and socioeconomic class).

Methods

We conducted a cross-sectional observational study of all individuals who presented with at least one chronic disease in 2019 (n = 1 086 948) from the EpiChron Cohort (Aragon, Spain). Applying intersectional analysis, the age-adjusted likelihood of multimorbidity was investigated across 36 intersectional strata defined by gender, ethnicity, residence area and socioeconomic class. We calculated odds ratios (OR) 95% confidence interval (CI) using high-income urban non-migrant men as the reference category. The area under the receiver operator characteristics curve (AUC) was calculated to evaluate the discriminatory accuracy of multimorbidity.

Results

The prevalence of multimorbidity increased with age, female gender and low income. Young and middle-aged low-income individuals showed rates of multimorbidity equivalent to those of high-income people aged about 20 years older. The intersectional analysis showed that low-income migrant women living in urban areas for >15 years were particularly disadvantaged in terms of multimorbidity risk OR = 3.16 (95% CI = 2.79-3.57). Being a migrant was a protective factor for multimorbidity, and newly arrived migrants had lower multimorbidity rates than those with >15 years of stay in Aragon, and even non-migrants. Living in rural vs. urban areas was slightly protective against multimorbidity. All models had a large discriminatory accuracy (AUC = 0.7884-0.7895); the largest AUC was obtained for the model including all intersectional strata.

Conclusions

Our intersectional approach uncovered the large differences in the prevalence of multimorbidity that arise due to the synergies between the different socioeconomic and demographic exposures, beyond their expected additive effects.

Multimorbidity Clusters in the Oldest Old: Results from the EpiChron Cohort

Multimorbidity is challenging for both patients and healthcare systems due to its increasing prevalence and high impact on people's health and well-being. The risk of multimorbidity increases with age, but there is still more to discover regarding the clinical profile of the oldest old. In this study, we used information from the EpiChron Cohort Study to identify multimorbidity patterns in individuals who died during the period 2010-2019 at the ages of 80-89, 90-99, and ≥100. This cohort links the demographic, clinical, and drug dispensation information of public health system users in Aragón, Spain. We saw a significantly lower number of chronic diseases and drugs and a lower prevalence of polypharmacy in centenarians compared to those aged 80-99. K-means clustering revealed different multimorbidity clusters by sex and age group. We observed clusters of cardiovascular and metabolic diseases, obstructive pulmonary conditions, and neoplasms, amongst other profiles. One in three octogenarian women had a metabolic pattern (diabetes, dyslipidaemia, and other endocrine-metabolic disorders) with the highest number of diseases (up to seven) and prevalence of polypharmacy (64%). We observed clusters of dementia and genitourinary disorders in individuals on medication with anticholinergic activity. Our study offers an opportunity to better understand the urgency of adequately addressing multimorbidity in our older adults.

Clinical characteristics of heart failure patients with mid-range ejection fraction

BACKGROUND

We aimed to characterise and compare the clinical profile of heart failure (HF) with mid-range (HFmrEF), reduced (HFrEF) and preserved (HFpEF) left-ventricular ejection fraction.

METHODS

We conducted a descriptive, observational study in 267 HF patients admitted to the Internal Medicine department of a tertiary hospital during 2010-2016. The study population was divided into three groups according to the ejection fraction rate: HFrEF (<40%), HFmrEF (40-49%), and HFpEF (≥50%). We analysed and compared their demographic, clinical, and analytical characteristics.

RESULTS

The mean age of the study population was 79.5 (standard deviation, 8.14) years; 56.6% were males. The most common phenotype was HFpEF (58.1%), followed by HFrEF (21.7%) and HFmrEF (20.2%). Ischaemic cardiopathy was the primary aetiology in the HFmrEF and HFrEF groups, and arterial hypertension in the HFpEF group. The most common comorbidities among HFmrEF patients were diabetes (43.4%), chronic obstructive pulmonary disease (35.8%), and anaemia (35.8%); 49.1% had impairment of segmental myocardial contractility, and 35.8% ventricular dilatation. No differences in HF outcomes were observed among the three phenotypes.

CONCLUSION

HFmrEF shows characteristics similar to both HFpEF and HFrEF. Further large-scale studies with longer follow-up are needed to ascertain if it is worth distinguishing this phenotype in clinical practice in terms of management and prognosis.

Sex differences in social support perceived by polymedicated older adults with multimorbidity. MULTIPAP study

The beneficial effects of social support on morbidity, mortality, and quality of life are well known. Using the baseline data of the MULTIPAP study (n = 593), an observational, descriptive, cross-sectional study was carried out that analyzed the sex differences in the social support perceived by polymedicated adults aged 65 to 74 years with multimorbidity. The main outcome variable was social support measured through the Duke-UNC-11 Functional Social Support (DUFSS) questionnaire in its two dimensions (confident support and affective support). For both sexes, the perception of functional social support was correlated with being married or partnered and having a higher health-related quality of life utility index. In women, it was correlated with a higher level of education, living alone, and treatment adherence, and in men with higher monthly income, prescribed drugs and fewer diagnosed diseases.

Effectiveness of the MULTIPAP Plus intervention in youngest-old patients with multimorbidity and polypharmacy aimed at improving prescribing practices in primary care: study protocol of a cluster randomized trial

Background

The progressive ageing of the population is leading to an increase in multimorbidity and polypharmacy, which in turn may increase the risk of hospitalization and mortality. The enhancement of care with information and communications technology (ICT) can facilitate the use of prescription evaluation tools and support system for decision-making (DSS) with the potential of optimizing the healthcare delivery process.

Objective

To assess the effectiveness and cost-effectiveness of the complex intervention MULTIPAP Plus, compared to usual care, in improving prescriptions for young-old patients (65-74 years old) with multimorbidity and polypharmacy in primary care.

Methods/design

This is a pragmatic cluster-randomized clinical trial with a follow-up of 18 months in health centres of the Spanish National Health System. Unit of randomization: family physician. Unit of analysis: patient.

Population

Patients aged 65–74 years with multimorbidity (≥ 3 chronic diseases) and polypharmacy (≥ 5 drugs) during the previous 3 months were included.

Sample size

n = 1148 patients (574 per study arm).

Intervention

Complex intervention based on the ARIADNE principles with three components: (1) family physician (FP) training, (2) FP-patient interview, and (3) decision-making support system.

Outcomes

The primary outcome is a composite endpoint of hospital admission or death during the observation period measured as a binary outcome, and the secondary outcomes are number of hospital admission, all-cause mortality, use of health services, quality of life (EQ-5D-5L), functionality (WHODAS), falls, hip fractures, prescriptions and adherence to treatment. Clinical and sociodemographic factors will be explanatory variables.

Statistical analysis

The main result is the difference in percentages in the final composite endpoint variable at 18 months, with its corresponding 95% CI. Adjustments by the main confounding and prognostic factors will be performed through a multilevel analysis. All analyses will be carried out in accordance to the intention-to-treat principle.

Discussion

It is important to prevent the cascade of negative health and health care impacts attributable to the multimorbidity-polypharmacy binomial. ICT-enhanced routine clinical practice could improve the prescription process in patient care.

Trial registration

ClinicalTrials.gov NCT04147130. Registered on 22 October 2019

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06293-x.

FAIR4Health: Findable, Accessible, Interoperable and Reusable data to foster Health Research

Due to the nature of health data, its sharing and reuse for research are limited by ethical, legal and technical barriers. The FAIR4Health project facilitated and promoted the application of FAIR principles in health research data, derived from the publicly funded health research initiatives to make them Findable, Accessible, Interoperable, and Reusable (FAIR). To confirm the feasibility of the FAIR4Health solution, we performed two pathfinder case studies to carry out federated machine learning algorithms on FAIRified datasets from five health research organizations. The case studies demonstrated the potential impact of the developed FAIR4Health solution on health outcomes and social care research. Finally, we promoted the FAIRified data to share and reuse in the European Union Health Research community, defining an effective EU-wide strategy for the use of FAIR principles in health research and preparing the ground for a roadmap for health research institutions. This scientific report presents a general overview of the FAIR4Health solution: from the FAIRification workflow design to translate raw data/metadata to FAIR data/metadata in the health research domain to the FAIR4Health demonstrators' performance.

Multimorbidity Profiles and Infection Severity in COVID-19 Population Using Network Analysis in the Andalusian Health Population Database

Identifying the population at risk of COVID-19 infection severity is a priority for clinicians and health systems. Most studies to date have only focused on the effect of specific disorders on infection severity, without considering that patients usually present multiple chronic diseases and that these conditions tend to group together in the form of multimorbidity patterns. In this large-scale epidemiological study, including primary and hospital care information of 166,242 patients with confirmed COVID-19 infection from the Spanish region of Andalusia, we applied network analysis to identify multimorbidity profiles and analyze their impact on the risk of hospitalization and mortality. Our results showed that multimorbidity was a risk factor for COVID-19 severity and that this risk increased with the morbidity burden. Individuals with advanced cardio-metabolic profiles frequently presented the highest infection severity risk in both sexes. The pattern with the highest severity associated in men was present in almost 28.7% of those aged ≥ 80 years and included associations between cardiovascular, respiratory, and metabolic diseases; age-adjusted odds ratio (OR) 95% confidence interval (1.71 (1.44–2.02)). In women, similar patterns were also associated the most with infection severity, in 7% of 65–79-year-olds (1.44 (1.34–1.54)) and in 29% of ≥80-year-olds (1.35 (1.18–1.53)). Patients with mental health patterns also showed one of the highest risks of COVID-19 severity, especially in women. These findings strongly recommend the implementation of personalized approaches to patients with multimorbidity and SARS-CoV-2 infection, especially in the population with high morbidity burden.

Identifying multimorbidity profiles associated with COVID-19 severity in chronic patients using network analysis in the PRECOVID Study

A major risk factor of COVID-19 severity is the patient's health status at the time of the infection. Numerous studies focused on specific chronic diseases and identified conditions, mainly cardiovascular ones, associated with poor prognosis. However, chronic diseases tend to cluster into patterns, each with its particular repercussions on the clinical outcome of infected patients. Network analysis in our population revealed that not all cardiovascular patterns have the same risk of COVID-19 hospitalization or mortality and that this risk depends on the pattern of multimorbidity, besides age and sex. We evidenced that negative outcomes were strongly related to patterns in which diabetes and obesity stood out in older women and men, respectively. In younger adults, anxiety was another disease that increased the risk of severity, most notably when combined with menstrual disorders in women or atopic dermatitis in men. These results have relevant implications for organizational, preventive, and clinical actions to help meet the needs of COVID-19 patients.

Chronic diseases associated with increased likelihood of hospitalization and mortality in 68,913 COVID-19 confirmed cases in Spain: A population-based cohort study

Background

Clinical outcomes among COVID-19 patients vary greatly with age and underlying comorbidities. We aimed to determine the demographic and clinical factors, particularly baseline chronic conditions, associated with an increased risk of severity in COVID-19 patients from a population-based perspective and using data from electronic health records (EHR).

Methods

Retrospective, observational study in an open cohort analyzing all 68,913 individuals (mean age 44.4 years, 53.2% women) with SARS-CoV-2 infection between 15 June and 19 December 2020 using exhaustive electronic health registries. Patients were followed for 30 days from inclusion or until the date of death within that period. We performed multivariate logistic regression to analyze the association between each chronic disease and severe infection, based on hospitalization and all-cause mortality.

Results

5885 (8.5%) individuals showed severe infection and old age was the most influencing factor. Congestive heart failure (odds ratio -OR- men: 1.28, OR women: 1.39), diabetes (1.37, 1.24), chronic renal failure (1.31, 1.22) and obesity (1.21, 1.26) increased the likelihood of severe infection in both sexes. Chronic skin ulcers (1.32), acute cerebrovascular disease (1.34), chronic obstructive pulmonary disease (1.21), urinary incontinence (1.17) and neoplasms (1.26) in men, and infertility (1.87), obstructive sleep apnea (1.43), hepatic steatosis (1.43), rheumatoid arthritis (1.39) and menstrual disorders (1.18) in women were also associated with more severe outcomes.

Conclusions

Age and specific cardiovascular and metabolic diseases increased the risk of severe SARS-CoV-2 infections in men and women, whereas the effects of certain comorbidities are sex specific. Future studies in different settings are encouraged to analyze which profiles of chronic patients are at higher risk of poor prognosis and should therefore be the targets of prevention and shielding strategies.

Multimorbidity clusters among long-term breast cancer survivors in Spain: Results of the SURBCAN study

The disease management of long-term breast cancer survivors (BCS) is hampered by the scarce knowledge of multimorbidity patterns. The aim of our study was to identify multimorbidity clusters among long-term BCS and assess their impact on mortality and health services use. We conducted a retrospective study using electronic health records of 6512 BCS from Spain surviving at least 5 years. Hierarchical cluster analysis was used to identify groups of similar patients based on their chronic diagnoses, which were assessed using the Clinical Classifications Software. As a result, multimorbidity clusters were obtained, clinically defined and named according to the comorbidities with higher observed/expected prevalence ratios. Multivariable Cox and negative binomial regression models were fitted to estimate overall mortality risk and probability of contacting health services according to the clusters identified. 83.7% of BCS presented multimorbidity, essential hypertension (34.5%) and obesity and other metabolic disorders (27.4%) being the most prevalent chronic diseases at the beginning of follow-up. Five multimorbidity clusters were identified: C1-unspecific (29.9%), C2-metabolic and neurodegenerative (28.3%), C3-anxiety and fractures (9.7%), C4-musculoskeletal and cardiovascular (9.6%) and C5-thyroid disorders (5.3%). All clusters except C5-thyroid disorders were associated with higher mortality compared to BCS without comorbidities. The risk of mortality in C4 was increased by 64% (adjusted hazard ratio 1.64, 95% confidence interval 1.52-2.07). Stratified analysis showed an increased risk of death among BCS with 5 to 10 years of survival in all clusters. These results help to identify subgroups of long-term BCS with specific needs and mortality risks and to guide BCS clinical practice regarding multimorbidity.

Changes in Multimorbidity and Polypharmacy Patterns in Young and Adult Population over a 4-Year Period: A 2011-2015 Comparison Using Real-World Data

The pressing problem of multimorbidity and polypharmacy is aggravated by the lack of specific care models for this population. We aimed to investigate the evolution of multimorbidity and polypharmacy patterns in a given population over a 4-year period (2011–2015). A cross-sectional, observational study among the EpiChron Cohort, including anonymized demographic, clinical and drug dispensation information of all users of the public health system ≥65 years in Aragon (Spain), was performed. An exploratory factor analysis, stratified by age and sex, using an open cohort was carried out based on the tetra-choric correlations among chronic diseases and dispensed drugs during 2011 and compared with 2015. Seven baseline patterns were identified during 2011 named as: mental health, respiratory, allergic, mechanical pain, cardiometabolic, osteometabolic, and allergic/derma. Of the epidemiological patterns identified in 2015, six were already present in 2011 but a new allergic/derma one appeared. Patterns identified in 2011 were more complex in terms of both disease and drugs. Results confirmed the existing association between age and clinical complexity. The systematic associations between diseases and drugs remain similar regarding their clinical nature over time, helping in early identification of potential interactions in multimorbid patients with a high risk of negative health outcomes due to polypharmacy.

Overuse or underuse? Use of healthcare services among irregular migrants in a north-eastern Spanish region

Background

There is little verified information on global healthcare utilization by irregular migrants. Understanding how immigrants use healthcare services based on their needs is crucial to establish effective health policy. We compared healthcare utilization between irregular migrants, documented migrants, and Spanish nationals in a Spanish autonomous community.

Methods

This retrospective, observational study included the total adult population of Aragon, Spain: 930,131 Spanish nationals; 123,432 documented migrants; and 17,152 irregular migrants. Healthcare utilization data were compared between irregular migrants, documented migrants and Spanish nationals for the year 2011. Multivariable standard or zero-inflated negative binomial regression models were generated, adjusting for age, sex, length of stay, and morbidity burden.

Results

The average annual use of healthcare services was lower for irregular migrants than for documented migrants and Spanish nationals at all levels of care analyzed: primary care (0.5 vs 4 vs 6.7 visits); specialized care (0.2 vs 1.8 vs 2.9 visits); planned hospital admissions (0.3 vs 2 vs 4.23 per 100 individuals), unplanned hospital admissions (0.5 vs 3.5 vs 5.2 per 100 individuals), and emergency room visits (0.4 vs 2.8 vs 2.8 per 10 individuals). The average annual prescription drug expenditure was also lower for irregular migrants (€9) than for documented migrants (€77) and Spanish nationals (€367). These differences were only partially attenuated after adjusting for age, sex, and morbidity burden.

Conclusions

Under conditions of equal access, healthcare utilization is much lower among irregular migrants than Spanish nationals (and lower than that of documented migrants), regardless of country of origin or length of stay in Spain.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-020-01373-3.

Comorbidity in an Older Population with Type-2 Diabetes Mellitus: Identification of the Characteristics and Healthcare Utilization of High-Cost Patients

Objectives: Little is known about the specific comorbidities contributing to higher costs in patients with type-2 diabetes mellitus (T2DM), particularly in older cases. We aimed to evaluate the prevalence, type, and cost of comorbidities occurring in older T2DM patients versus older non-T2DM patients, and the factors associated with high cost (HC) T2DM patients. Methods: Retrospective cohort study using information from the Campania Region healthcare database. People aged ≥65 years who received ≥2 prescriptions for antidiabetic drugs were identified as "T2DM patients." Comorbidities among T2DM and non-T2DM groups were assessed through the RxRiskV Index (modified version). T2DM individuals were classified according to the total cost distribution as HC or "non-high cost." Two sub-cohorts of HC T2DM patients were assessed: above 90th and 80th percentile of the total cost. Age- and sex-adjusted logistic regression models were created. Results: Among the T2DM cohort, concordant and discordant comorbidities occurred significantly more frequently than in the non-T2DM cohort. Total mean annual cost per T2DM patient due to comorbidities was €7,627 versus €4,401 per non-T2DM patient. Among T2DM patients identified as being above 90th and 80th percentiles of cost distribution, the total annual costs were >€19,577 and >€2,563, respectively. The hospitalization cost was higher for T2DM cases. Strongest predictors of being a HC T2DM patient were having ≥5 comorbidities and renal impairment. Conclusion: HC patients accrued >80% of the total comorbidities cost in older T2DM patients. Integrated care models, with holistic and patient-tailored foci, could achieve more effective T2DM care.

Chronic Obstructive Pulmonary Disease and Incidence of Hip Fracture: A Nested Case-Control Study in the EpiChron Cohort

Purpose

To determine whether chronic obstructive pulmonary disease (COPD) is a risk factor for hip fracture and identify other factors associated with hip fracture.

Patients and Methods

Observational nested case-control study was conducted in Aragon, Spain in 2010. We included COPD patients aged >40 years, in the EpiChron cohort. Each COPD patient was matched for age, sex, and number of comorbidities with a control subject without COPD. Patients with an existing diagnosis of osteoporosis and those with hip fracture before 2011 were excluded. We collected baseline demographic, comorbidity, and pharmacological treatment data. During a 5-year follow-up period, we recorded the incidence of hip fracture. A logistic regression model was constructed to identify factors associated with hip fracture.

Results

The study population consisted of 26,517 COPD patients and the same number of controls (median [interquartile range] age, 74 [17] years; women, 24.7%). Smoking and heart failure were more frequent in COPD patients, and obesity, hypertension, diabetes, dyslipidemia, stroke, arthritis, and visual or hearing impairment were less frequent (all p<0.001). Consumption of benzodiazepines (p=0.037), bronchodilators (p<0.001), and corticosteroids (p<0.001) was higher in the COPD group, while that of beta-blockers and thiazides was lower (both p<0.001). During follow-up, 898 (1.7%) patients experienced hip fracture, with no differences observed between COPD and control patients. Multivariate analysis revealed that independent of COPD status, age, female sex, chronic liver disease, heart failure, and benzodiazepine use were independently associated with a higher risk of hip fracture, and obesity with a lower risk. In COPD patients, use of inhaled anticholinergics was independently associated with hip fracture (OR, 1.390; 95% CI 1.134-1.702; p=0.001).

Conclusion

COPD is not a risk factor for a hip fracture within 5 years. The association between the use of inhaled anticholinergics and risk of hip fracture warrants further study.

Association between mental health comorbidity and health outcomes in type 2 diabetes mellitus patients

Type 2 diabetes mellitus (T2D) is often accompanied by chronic diseases, including mental health problems. We aimed at studying mental health comorbidity prevalence in T2D patients and its association with T2D outcomes through a retrospective, observational study of individuals of the EpiChron Cohort (Aragón, Spain) with prevalent T2D in 2011 (n = 63,365). Participants were categorized as having or not mental health comorbidity (i.e., depression, anxiety, schizophrenia, and/or substance use disorder). We performed logistic regression models, controlled for age, sex and comorbidities, to analyse the likelihood of 4-year mortality, 1-year all-cause hospitalization, T2D-hospitalization, and emergency room visit. Mental health comorbidity was observed in 19% of patients. Depression was the most frequent condition, especially in women (20.7% vs. 7.57%). Mortality risk was higher in patients with mental health comorbidity (odds ratio 1.24; 95% confidence interval 1.16-1.31), especially in those with substance use disorder (2.18; 1.84-2.57) and schizophrenia (1.82; 1.50-2.21). Mental health comorbidity also increased the likelihood of all-cause hospitalization (1.16; 1.10-1.23), T2D-hospitalization (1.51; 1.18-1.93) and emergency room visit (1.26; 1.21-1.32). These results suggest that T2D healthcare management should include specific strategies for the early detection and treatment of mental health problems to reduce its impact on health outcomes.

Multimorbidity networks of chronic obstructive pulmonary disease and heart failure in men and women: Evidence from the EpiChron Cohort

Patients with heart failure (HF) and/or chronic obstructive pulmonary disease (COPD) constitute a complex population with different phenotypes based on pathophysiology, comorbidity, sex and age. We aimed to compare the multimorbidity patterns of HF and COPD in men and women using network analysis. Individuals aged 40 years or older on 2015 of the EpiChron Cohort (Aragon, Spain) were stratified by sex and as having COPD (n = 28,608), HF (n = 13,414), or COPD and HF (n = 3952). We constructed one network per group by obtaining age-adjusted phi correlations between comorbidities. For each sex, networks differed between the three study groups; between sexes, similarities were found for the two HF groups. We detected some specific diseases highly connected in all networks (e.g., cardio-metabolic, respiratory diseases, and chronic kidney failure), and some others that were group-specific that would require further study. We identified common clusters (i.e., cardio-metabolic, cardiovascular, cancer, and neuro-psychiatric) and others specific and clinically relevant in COPD patients (e.g., behavioral risk disorders were systematically associated with psychiatric diseases in women and cancer in men). Network analysis represents a powerful tool to analyze, visualize, and compare the multimorbidity patterns of COPD and HF, also facilitated by developing an ad hoc website.

Use of real-world data to study health services utilisation and comorbidities in long-term breast cancer survivors (the SURBCAN study): study protocol for a longitudinal population-based cohort study

INTRODUCTION

Breast cancer has become a chronic disease due to survival improvement and the need to monitor the side effects of treatment and the disease itself. The aim of the SURBCAN study is to describe comorbidity, healthcare services use and adherence to preventive recommendations in long-term breast cancer survivors and to compare them with those in women without this diagnosis in order to improve and adapt the care response to this group of survivors.

METHODS AND ANALYSIS

Population-based retrospective cohort study using real-world data from cancer registries and linked electronic medical records in five Spanish regions. Long-term breast cancer survivors diagnosed between 2000 and 2006 will be identified and matched by age and administrative health area with women without this diagnosis. Sociodemographic and clinical variables including comorbidities and variables on the use of health services between 2012 and 2016 will be obtained from databases in primary and hospital care. Health services use will be assessed through the annual number of visits to primary care professionals and to specialists and through annual imaging and laboratory tests. Factors associated with healthcare utilisation and comorbidities will be analysed using multilevel logistic regression models. Recruitment started in December 2018.

ETHICS AND DISSEMINATION

This study was approved by the Ethics Committee of Parc de Salut Mar. The results of the study will be published in a peer-reviewed journal and will be presented at national and international scientific conferences and at patient associations.

TRIAL REGISTRATION NUMBER

This protocol is registered in Clinical Trials.gov (identifier: NCT03846999).

Examining the impact of mental disease on type 2 diabetes outcomes: results from the EpiChron Cohort

Background

Type 2 diabetes mellitus (T2D) is often accompanied by other chronic diseases, including mental diseases (MD). This work aimed at studying MD prevalence in T2D patients and analyse its impact on T2D health outcomes.

Methods

Retrospective, observational study of individuals of the EpiChron Cohort aged 18 and over with prevalent T2D at baseline (2011) in Aragón, Spain (n = 63,365). Participants were categorized by the existence or absence of MD, defined as the presence of depression, anxiety, schizophrenia or substance abuse. MD prevalence was calculated, and a logistic regression model was performed to analyse the likelihood of the four studied health outcomes (4-year all-cause mortality, all-cause hospitalization, T2D-hospitalization, and emergency room visits) based on the presence of each type of MD, after adjusting by age, sex and number of comorbidities.

Results

Mental diseases were observed in 19% of T2D patients, with depression being the most frequent condition, especially in women (20.7% vs. 7.57%). Mortality risk was significantly higher in patients with MD (odds ratio -OR- 1.24; 95% confidence interval -CI- 1.16-1.31), especially in those with substance abuse (OR 2.18; 95% CI 1.84-2.57) and schizophrenia (OR 1.82; 95% CI 1.50-2.21). The presence of MD also increased the risk of T2D-hospitalization (OR 1.51; 95% CI 1.18-1.93), emergency room visits (OR 1.26; 95% CI 1.21-1.32) and all-cause hospitalization (OR 1.16; 95% CI 1.10-1.23).

Conclusions

The high prevalence of MD among T2D patients, and its association with health outcomes, underscores the importance of providing integrated, person-centred care and early detection of comorbid mental diseases in T2D patients to improve disease management and health outcomes.

Key messages

Comprehensive care of T2D should include specific strategies for prevention, early detection, and management of comorbidities, especially mental disorders, in order to reduce their impact on health. Substance abuse was the mental disease with the highest risk of T2D-hospitalization, emergency room visits and all-cause hospitalization.

Potentially inappropriate prescriptions according to explicit and implicit criteria in patients with multimorbidity and polypharmacy. MULTIPAP: A cross-sectional study

Background

Multimorbidity is a global health challenge that is associated with polypharmacy, increasing the risk of potentially inappropriate prescribing (PIP). There are tools to improve prescription, such as implicit and explicit criteria.

Objective

To estimate the prevalence of PIP in a population aged 65 to 74 years with multimorbidity and polypharmacy, according to American Geriatrics Society Beers Criteria^® (2015, 2019), the Screening Tool of Older Person’s Prescription -STOPP- criteria (2008, 2014), and the Medication Appropriateness Index -MAI- criteria in primary care.

Methods

This was an observational, descriptive, cross-sectional study. The sample included 593 community-dwelling elderly aged 65 to 74 years, with multimorbidity and polypharmacy, who participated in the MULTIPAP trial. Socio-demographic, clinical, professional, and pharmacological-treatment variables were recorded. Potentially inappropriate prescribing was detected by computerized prescription assistance system, and family doctors evaluated the MAI. The MAI-associated factors were analysed using a logistic regression model.

Results

A total of 4,386 prescriptions were evaluated. The mean number of drugs was 7.4 (2.4 SD). A total of 94.1% of the patients in the study had at least one criterion for drug inappropriateness according to the MAI. Potentially inappropriate prescribing was detected in 57.7%, 43.6%, 68.8% and 71% of 50 patients according to the explicit criteria STOPP 2014, STOPP 2008, Beers 2019 and Beers 2015 respectively. For every new drug taken by a patient, the MAI score increased by 2.41 (95% CI 1.46; 3.35) points. Diabetes, ischaemic heart disease and asthma were independently associated with lower summated MAI scores.

Conclusions

The prevalence of potentially inappropriate prescribing detected in the sample was high and in agreement with previous literature for populations with multimorbidity and polypharmacy. The MAI criteria detected greater inappropriateness than did the explicit criteria, but their application was more complex and difficult to automate.

Assessing the Pilot Implementation of the Integrated Multimorbidity Care Model in Five European Settings: Results from the Joint Action CHRODIS-PLUS

Multimorbidity, the coexistence of several chronic conditions in a patient, represents a great challenge for healthcare systems and society. The Integrated Multimorbidity Care Model (IMCM) was recently designed within the Joint Action on chronic diseases and promoting healthy ageing across the life cycle (CHRODIS) to ensure the continuity of care for patients with multimorbidity. The IMCM was implemented in five European pilot sites in Spain, Italy, and Lithuania, within the Joint Action CHRODIS-PLUS. The effect of these pilot interventions was assessed pre- and post-implementation by 17 healthcare managers, using the Assessment of Chronic Illness Care (ACIC) measure, and by 226 patients with the Patient Assessment of Care for Chronic Conditions (PACIC+) survey. The ACIC total score significantly increased (5.23 to 6.71, p = 0.022) after the intervention, with differences across sites. A significant increase in the PACIC+ summary score was found ranging from 3.25 at baseline to 4.03 after the intervention (p < 0.001), and 58% of the sample perceived an improvement in care. Higher PACIC+ scores after the intervention were associated to lower baseline values in the respective PACIC+ dimension and to greater changes in ACIC Part 1 (delivery system organization). The IMCM implementation can help improve the quality of care for patients with multimorbidity.

Multimorbidity and chronic diseases among undocumented migrants: evidence to contradict the myths

Background

There is little verified information on the global health status of undocumented migrants (UMs). Our aim is to compare the prevalence of the main chronic diseases and of multimorbidity in undocumented migrants, documented migrants, and Spanish nationals in a Spanish autonomous community.

Methods

Retrospective observational study of all users of the public health system of the region of Aragon over 1 year (2011): 930,131 Spanish nationals; 123,432 documented migrants (DMs); and 17,152 UMs. Binary logistic regression was performed to examine the association between migrant status (Spanish nationals versus DMs and UMs) and both multimorbidity and individual chronic diseases, adjusting for age and sex.

Results

The prevalence of individual chronic diseases in UMs was lower than in DMs and much lower than in Spanish nationals. Comparison with the corresponding group of Spanish nationals revealed odds ratios (OR) of 0.1–0.3 and 0.3–0.5 for male and female UMs, respectively (p < 0.05 in all cases). The risk of multimorbidity was lower for UMs than DMs, both for men (OR, 0.12; 95%CI 0.11–0.13 versus OR, 0.53; 95%CI 0.51–0.54) and women (OR, 0.18; 95%CI 0.16–0.20 versus OR, 0.74; 95%CI 0.72–0.75).

Conclusions

Analysis of data from a health system that offers universal coverage to all immigrants, irrespective of legal status, reveals that the prevalence of chronic disease and multimorbidity is lower in UMs as compared with both DMs and Spanish nationals. These findings refute previous claims that the morbidity burden in UM populations is higher than that of the native population of the host country.

Prevalence and Comorbidity of Atopic Dermatitis in Children: A Large-Scale Population Study Based on Real-World Data

This study aimed at exploring atopic dermatitis (AD) prevalence in children and exhaustively analyzing their comorbidity. We conducted a descriptive analysis of their socio-demographic and comorbidity characteristics in the EpiChron Cohort (Aragón, Spain). Adjusted odds ratios (OR) were calculated for each comorbidity using logistic regression models. In total, 33,591 children had a diagnosis of AD, resulting in an overall prevalence of 15.5%. AD prevalence was higher in girls compared to boys, in 3–9-year-olds compared to children of other ages, and in Spanish children compared to those of other nationalities. Multimorbidity was present in 43% of children, with the most frequent chronic comorbidities being asthma (13.1%), psychosocial disorders (7.9%), and visual impairment (7.8%). Many diseases were, regardless of their prevalence, statistically associated with AD. The strongest associations (odds ratio (OR) (95% confidence interval (CI))) were found in asthma (2.10 (2.02–2.17)), allergic rhinitis (2.00 (1.91–2.10)), and irritable bowel syndrome (1.90 (1.56–2.31)). A better understanding of the array of comorbidities associated with AD in children might help improve their clinical management. Future longitudinal studies are encouraged to shed light on the potential underlying pathophysiological mechanisms involved in the identified associations.

Do Centenarians Die Healthier than Younger Elders? A Comparative Epidemiological Study in Spain

This study aims to describe the clinical course, drug use, and health services use characteristics during the last year of life of elders who die being centenarians and to identify key aspects differentiating them from elders who die at an earlier age, with a particular focus on sex differences. We conducted an observational, population-based study in the EpiChron Cohort (Aragón, Spain). The population was stratified by sex and into three age sub-populations (80-89, 90-99, and ≥100 years), and their characteristics were described and compared. Multimorbidity was the rule in our elders, affecting up to 3 in 4 centenarians and 9 in 10 octogenarians and nonagenarians. Polypharmacy was also observed in half of the centenarian population and in most of the younger elders. Risk factors for cardiovascular disease (i.e., hypertension, dyslipidaemia, diabetes), cerebrovascular disease and dementia were amongst the most common chronic conditions in all age groups, whereas the gastroprotective drugs and antithrombotic agents were the most dispensed drugs. Centenarians presented in general lower morbidity and treatment burden and lower use of both primary and hospital healthcare services than octogenarians and nonagenarians, suggesting a better health status. Sex-differences in their clinical characteristics were more striking in octogenarians and tended to decrease with age.

Sex Differences in Comorbidity, Therapy, and Health Services' Use of Heart Failure in Spain: Evidence from Real-World Data

Heart failure (HF) is becoming increasingly prevalent and affects both men and women. However, women have traditionally been underrepresented in HF clinical trials. In this study, we aimed to analyze sex differences in the comorbidity, therapy, and health services’ use of HF patients. We conducted a cross-sectional study in Aragón (Spain) and described the characteristics of 17,516 patients with HF. Women were more frequent (57.4 vs. 42.6%, p < 0.001) and older (83 vs. 80 years, p < 0.001) than men, and presented a 33% lower risk of 1-year mortality (p < 0.001). Both sexes showed similar disease burdens, and 80% suffered six or more diseases. Some comorbidities were clearly sex-specific, such as arthritis, depression, and hypothyroidism in women, and arrhythmias, ischemic heart disease, and COPD in men. Men were more frequently anti-aggregated and anti-coagulated and received more angiotensin-converting-enzyme (ACE) inhibitors and beta-blockers, whereas women had more angiotensin II antagonists, antiinflammatories, antidepressants, and thyroid hormones dispensed. Men were admitted to specialists (79.0 vs. 70.6%, p < 0.001), hospital (47.0 vs. 38.1%, p < 0.001), and emergency services (57.6 vs. 52.7%, p < 0.001) more frequently than women. Our results highlight the need to conduct future studies to confirm the existence of these differences and of developing separate HF management guidelines for men and women that take into account their sex-specific comorbidity.

Multimorbidity patterns in patients with heart failure: an observational Spanish study based on electronic health records

OBJECTIVES

To characterise the comorbidities of heart failure (HF) in men and women, to explore their clustering into multimorbidity patterns, and to measure the impact of such patterns on the risk of hospitalisation and mortality.

DESIGN

Observational retrospective population study based on electronic health records.

SETTING

EpiChron Cohort (Aragón, Spain).

PARTICIPANTS

All the primary and hospital care patients of the EpiChron Cohort with a diagnosis of HF on 1 January 2011 (ie, 8488 women and 6182 men). We analysed all the chronic diseases registered in patients' electronic health records until 31 December 2011.

PRIMARY OUTCOME

We performed an exploratory factor analysis to identify the multimorbidity patterns in men and women, and logistic and Cox proportional-hazards regressions to investigate the association between the patterns and the risk of hospitalisation in 2012, and of 3-year mortality.

RESULTS

Almost all HF patients (98%) had multimorbidity, with an average of 7.8 chronic diseases per patient. We identified six different multimorbidity patterns, named cardiovascular, neurovascular, coronary, metabolic, degenerative and respiratory. The most prevalent were the degenerative (64.0%) and cardiovascular (29.9%) patterns in women, and the metabolic (49.3%) and cardiovascular (43.2%) patterns in men. Every pattern was associated with higher hospitalisation risks; and the cardiovascular, neurovascular and respiratory patterns significantly increased the likelihood of 3-year mortality.

CONCLUSIONS

Multimorbidity is the norm rather than the exception in patients with heart failure, whose comorbidities tend to cluster together beyond simple chance in the form of multimorbidity patterns that have different impact on health outcomes. This knowledge could be useful to better understand common pathophysiological pathways underlying this condition and its comorbidities, and the factors influencing the prognosis of men and women with HF. Further large scale longitudinal studies are encouraged to confirm the existence of these patterns as well as their differential impact on health outcomes.

Application of the JA-CHRODIS Integrated Multimorbidity Care Model (IMCM) to a Case Study of Diabetes and Mental Health

The Integrated Multimorbidity Care Model (IMCM), developed by the Joint Action on Chronic Diseases and Promoting Healthy Ageing across the Life Cycle (JA-CHRODIS), proposes a set of 16 multidimensional components (i.e., recommendations) to improve the care of persons with multimorbidity in Europe. This study aimed at analyzing the potential applicability of the IMCM. We followed a qualitative approach that comprised two phases: (1) The design of a case study based on empirical clinical data, which consisted of a hypothetical woman with multimorbidity, type 2 diabetes mellitus, mental health, and associated social problems, and (2) the creation of a consensus group to gather the opinions of a multidisciplinary group of experts and consider the potential applicability of the IMCM to our case study. Experts described how care should be delivered to this patient according to each model component, suggested the use of specific rating scales and tools to assess her needs in a comprehensive and regular way, and pointed our crucial health and social resources to improve her care process. Experts also highlighted patient-centered, integrated and tailored care as one of the keystones of quality healthcare. Our results suggest that the IMCM is applicable in complex patients with multimorbidity.

A Methodological Approach for Implementing an Integrated Multimorbidity Care Model: Results from the Pre-Implementation Stage of Joint Action CHRODIS-PLUS

Patients with multimorbidity (defined as the co-occurrence of multiple chronic diseases) frequently experience fragmented care, which increases the risk of negative outcomes. A recently proposed Integrated Multimorbidity Care Model aims to overcome many issues related to fragmented care. In the context of Joint Action CHRODIS-PLUS, an implementation methodology was developed for the care model, which is being piloted in five sites. We aim to (1) explain the methodology used to implement the care model and (2) describe how the pilot sites have adapted and applied the proposed methodology. The model is being implemented in Spain (Andalusia and Aragon), Lithuania (Vilnius and Kaunas), and Italy (Rome). Local implementation working groups at each site adapted the model to local needs, goals, and resources using the same methodological steps: (1) Scope analysis; (2) situation analysis—“strengths, weaknesses, opportunities, threats” (SWOT) analysis; (3) development and improvement of implementation methodology; and (4) final development of an action plan. This common implementation strategy shows how care models can be adapted according to local and regional specificities. Analysis of the common key outcome indicators at the post-implementation phase will help to demonstrate the clinical effectiveness, as well as highlight any difficulties in adapting a common Integrated Multimorbidity Care Model in different countries and clinical settings.

Health of Spanish centenarians: a cross-sectional study based on electronic health records

Background

With the number of centenarians increasing exponentially in Spain, a deeper knowledge of their socio-demographic, clinical, and healthcare use characteristics is important to better understand the health profile of the very elderly.

Methods

We conducted a retrospective, cross-sectional observational study in the EpiChron Cohort (Aragón, Spain) aimed at analyzing the socio-demographic, clinical, drug use and healthcare use characteristics of 1680 centenarians during 2011–2015, using data from electronic health records and clinical-administrative databases.

Results

Spanish centenarians (79.1% women) had 101.6 years on average. Approximately 80% of centenarians suffered from multimorbidity, with an average of 4.0 chronic conditions; 50% were exposed to polypharmacy, with an average of 4.8 medications; only 6% of centenarians were free of chronic diseases and only 7% were not on medication. Centenarians presented a cardio-cerebrovascular pattern in which hypertension, heart failure, cerebrovascular disease and dementia were the most frequent conditions. Primary care was the most frequently visited healthcare level (79% of them), followed by medical specialist consultations (23%), hospitalizations (13%), and emergency service use (9%).

Conclusions

Multimorbidity is the rule rather than the exception in Spanish centenarians. Addressing medical care in the very elderly from a holistic geriatric view is critical in order to preserve their health, and avoid the negative effects of polypharmacy.

Antidepressant use in Denmark, Germany, Spain, and Sweden between 2009 and 2014: Incidence and comorbidities of antidepressant initiators

BACKGROUND

We aimed to describe patterns of use and characteristics of 10 commonly used antidepressants for the period 2009-2014 in Denmark, Germany, Spain, and Sweden.

METHODS

Adult initiators from 2009 to 2014 of each study antidepressant were identified in four countries using five data sources: the Danish National registers, GePaRD (Germany), EpiChron (Aragon, Spain), SIDIAP (Catalonia, Spain), and the Swedish National Registers. The study included 10 study antidepressants: citalopram, escitalopram, fluoxetine, paroxetine, sertraline, duloxetine, venlafaxine, amitriptyline, mirtazapine, and agomelatine.

RESULTS

Citalopram was the most prescribed study antidepressant, followed by mirtazapine. Paroxetine and agomelatine were the least prescribed antidepressants. Mirtazapine was widely used among older antidepressant initiators with higher percentages of comorbidities at baseline, and fluoxetine was used among young patients. Citalopram and amitriptyline had the lowest percentage of multiple antidepressant use in the 12 months prior to the current treatment episode, while agomelatine, duloxetine, and venlafaxine had the highest percentage of multiple antidepressant use in the year prior to the current treatment episode.

LIMITATIONS

The most important limitations are exposure information based on filled prescriptions, focus on antidepressant initiators only, lack of information on the indication, and heterogeneity of the type of data across data sources.

CONCLUSIONS

Results of this study including 4.8 million study antidepressant initiators of study antidepressants suggest that citalopram and mirtazapine are the most commonly prescribed antidepressants. Agomelatine and paroxetine were the least used antidepressants in the participating populations. Mirtazapine was the antidepressant most commonly prescribed among older antidepressant initiators with high percentage of comorbidities at baseline, whereas fluoxetine was commonly used among young patients.

Risk of Acute Liver Injury in Agomelatine and Other Antidepressant Users in Four European Countries: A Cohort and Nested Case-Control Study Using Automated Health Data Sources

BACKGROUND

Agomelatine is a melatonin receptor agonist and serotonin 5-HT2C receptor antagonist indicated for depression in adults. Hepatotoxic reactions like acute liver injury (ALI) are an identified risk in the European risk management plan for agomelatine. Hepatotoxic reactions have been reported for other antidepressants, but population studies quantifying these risks are scarce. Antidepressants are widely prescribed, and users often have risk factors for ALI (e.g. metabolic syndrome).

OBJECTIVE

The goal was to estimate the risk of ALI associated with agomelatine and other antidepressants (fluoxetine, paroxetine, sertraline, escitalopram, mirtazapine, venlafaxine, duloxetine, and amitriptyline) when compared with citalopram in routine clinical practice.

METHOD

A nested case-control study was conducted using data sources in Denmark, Germany, Spain, and Sweden (study period 2009-2014). Three ALI endpoints were defined using International Classification of Diseases (ICD) codes: primary (specific codes) and secondary (all codes) endpoints used only hospital discharge codes; the tertiary endpoint included both inpatient and outpatient settings (all codes). Validation of endpoints was implemented. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for current use were estimated for each data source and combined.

RESULTS

We evaluated 3,238,495 new antidepressant and 74,440 agomelatine users. For the primary endpoint, the OR for agomelatine versus citalopram was 0.48 (CI 0.13-1.71). Results were also < 1 when no exclusion criteria were applied (OR 0.37; CI 0.19-0.74), when all exclusion criteria except alcohol and drug abuse were applied (OR 0.47; CI 0.20-1.07), and for the secondary (OR 0.40; CI 0.05-3.11) and tertiary (OR 0.79; CI 0.50-1.25) endpoints. Regarding other antidepressants versus citalopram, most OR point estimates were also below one, although with varying widths of the 95% CIs. The result of the tertiary endpoint and the sensitivity analyses of the primary endpoint were the most precise.

CONCLUSION

In this study, using citalopram as a comparator, agomelatine was not associated with an increased risk of ALI hospitalisation. The results for agomelatine should be interpreted in the context of the European risk minimisation measures in place. Those measures may have induced selective prescribing and could explain the lower risk of ALI for agomelatine when compared with citalopram. Most other antidepressants evaluated had ORs suggesting a lower risk than citalopram, but additional studies are required to confirm or refute these results.

The definition of immigrant status matters: impact of nationality, country of origin, and length of stay in host country on mortality estimates

BACKGROUND

Mortality is a robust indicator of health and offers valuable insight into the health of immigrants. However, mortality estimates can vary significantly depending on the manner in which immigrant status is defined. Here, we assess the impact of nationality, country of origin, and length of stay in the host country on mortality estimates in an immigrant population in Aragón, Spain.

METHODS

Cross-sectional retrospective study of all adult subjects from the EpiChron Cohort in 2011 (n = 1,102,544), of whom 146,100 were foreign-born (i.e., according to place of birth) and 127,213 were non-nationals (i.e., according to nationality). Directly standardized death proportions between years 2012-2015 were calculated, taking into account the age distribution of the European population in 2013. Binary logistic regression was used to compare the four-year probability of death.

RESULTS

The age- and sex-standardized number of deaths per 1000 subjects were 45.1 (95%CI 44.7-45.2) for the Spanish-born population, 29.3 (95%CI 26.7-32.1) for the foreign-born population, and 18.4 (95%CI 15.6-21.6) for non-Spanish nationals. Compared with the Spanish-born population, the age- and sex-adjusted likelihood of dying was equally reduced in the foreign-born and non-national populations (OR 0.6; 95%CI 0.5-0.7) when the length of stay was less than 10 years. No significant differences in mortality estimates were detected when the length of stay was over 10 years.

CONCLUSIONS

Mortality estimates in immigrant populations were lower than those of the native Spanish population, regardless of the criteria applied. However, the proportion of deaths was lower when immigrant status was defined using nationality instead of country of birth. Age- and sex-standardized death proportions tended to increase with increased length of stay in the host country.

The Disease Burden Morbidity Assessment in older adults and its association with mortality and other health outcomes

The objective of this study was to assess how disease burden caused by chronic conditions is related to mortality (predictive validity) and other health outcomes (convergent validity). This was studied in 625 community-dwelling adults living in Spain aged 65 years and older. Disease burden was measured with the Disease Burden Morbidity Assessment (DBMA). The association with 5-year mortality was assessed using a Cox model and Kaplan-Meier curves. For convergent validity, mean age, sex ratio, patient-centered outcomes and healthcare utilization were compared for high and low DBMA scores (< 10 vs. ≥ 10). Also, a multivariable linear regression model was used to evaluate the DBMA as a function of these variables. Mean DBMA score in our sample was 7.5. After 5 years, 35 participants had died (5.5%). The Cox model displayed a hazard ratio of 1.07, and the Kaplan-Meier curves showed lower survival for high DBMA scores. Among participants with high DBMA scores, low self-perceived health, disability and female sex were more frequent, and this group showed lower mean scores for quality of life (Personal Wellbeing Index), affect balance (Scale of Positive and Negative Experience) and physical activity (Yale Physical Activity Survey), higher mean age and higher healthcare utilization than persons with low DBMA scores. In the multivariable regression, all variables but age were significantly associated with the DBMA. In conclusion, the DBMA showed satisfactory predictive and convergent validity. In our aging society, it can be applied to better understand and improve care for older persons with multiple chronic conditions.

Adherence to chronic medication in older populations: application of a common protocol among three European cohorts

PURPOSE

The purpose of this study was to evaluate and compare medication adherence to chronic therapies in older populations across different regions in Europe.

METHODS

This explorative study applied a harmonized method of data extraction and analysis from pharmacy claims databases of three European countries to compare medication adherence at a cross-country level. Data were obtained for the period between January 1, 2010, and December 31, 2011. Patients (aged ≥65 years) who newly initiated to oral antidiabetics, antihyperlipidemics, or antiosteoporotics were identified and followed for over a 12-month period. Main outcome measures were medication adherence (medication possession ratio, [MPR]; implementation) and persistence on index treatment. All country-specific data sets were prepared by employing a common data input model. Outcome measures were calculated for each country and pooled using random effect models.

RESULTS

In total, 39,186 new users were analyzed. In pooled data from the three countries, suboptimal implementation (MPR <80%) was 52.45% (95% CI: 33.43-70.79) for antihy-perlipidemics, 61.35% (95% CI: 52.83-69.22) for antiosteoporotics, and 30.33% (95% CI: 25.53-35.60) for oral antidiabetics. Similarly, rates of non-persistence (discontinuation) were 55.63% (95% CI: 35.24-74.29) for antihyperlipidemics, 60.24% (95% CI: 45.35-73.46) for antiosteoporotics, and 46.80% (95% CI: 36.40-57.4) for oral antidiabetics.

CONCLUSION

Medication adherence was suboptimal with >50% of older people non-adherent to antihyperlipidemics and antiosteoporotics in the three European cohorts. However, the degree of variability in adherence rates among the three countries was high. A harmonized method of data extraction and analysis across health-related database in Europe is useful to compare medication-taking behavior at a cross-country level.

Effectiveness of risk minimization measures for the use of cilostazol in United Kingdom, Spain, Sweden, and Germany

Purpose

The purpose of the study is to evaluate the effectiveness of risk minimization measures—labeling changes and communication to health care professionals—recommended by the European Medicines Agency for use of cilostazol for the treatment of intermittent claudication in Europe.

Methods

Observational study of cilostazol in The Health Improvement Network (United Kingdom), EpiChron Cohort (Spain), SIDIAP (Spain), Swedish National Databases, and GePaRD (Germany).

Among new users of cilostazol, we compared the prevalence of conditions targeted by the risk minimization measures in the periods before (2002‐2012) and after (2014) implementation. Conditions evaluated were prevalence of smoking, cardiovascular conditions, concurrent use of ≥2 antiplatelet agents, concurrent use of potent CYP3A4/CYP2C19 inhibitors and high‐dose cilostazol, early monitoring of all users, and continuous monitoring of users at high cardiovascular risk.

Results

We included 22 593 and 1821 new users of cilostazol before and after implementation of risk minimization measures, respectively. After implementation, the frequency of several conditions related to the labeling changes improved in all the study populations: prevalence of use decreased between 13% (EpiChron) and 57% (SIDIAP), frequency of cardiovascular contraindications decreased between 8% (GePaRD) and 84% (EpiChron), and concurrent use of high‐dose cilostazol and potent CYP3A4/CYP2C19 inhibitors decreased between 6% (Sweden) and 100% (EpiChron). The frequency of other conditions improved in most study populations, except smoking, which decreased only in EpiChron (48% reduction).

Conclusions

This study indicates that the risk minimization measures implemented by the EMA for the use of cilostazol have been effective in all European countries studied, except for smoking cessation before initiating cilostazol, which remains an area of improvement.

Chronic Obstructive Pulmonary Disease (COPD) as a disease of early aging: Evidence from the EpiChron Cohort

BACKGROUND

Aging is an important risk factor for most chronic diseases. Patients with COPD develop more comorbidities than non-COPD subjects. We hypothesized that the development of comorbidities characteristically affecting the elderly occur at an earlier age in subjects with the diagnosis of COPD.

METHODS AND FINDINGS

We included all subjects carrying the diagnosis of COPD (n = 27,617), and a similar number of age and sex matched individuals without the diagnosis, extracted from the 727,241 records of individuals 40 years and older included in the EpiChron Cohort (Aragon, Spain). We compared the cumulative number of comorbidities, their prevalence and the mortality risk between both groups. Using network analysis, we explored the connectivity between comorbidities and the most influential comorbidities in both groups. We divided the groups into 5 incremental age categories and compared their comorbidity networks. We then selected those comorbidities known to affect primarily the elderly and compared their prevalence across the 5 age groups. In addition, we replicated the analysis in the smokers' subgroup to correct for the confounding effect of cigarette smoking. Subjects with COPD had more comorbidities and died at a younger age compared to controls. Comparison of both cohorts across 5 incremental age groups showed that the number of comorbidities, the prevalence of diseases characteristic of aging and network's density for the COPD group aged 56-65 were similar to those of non-COPD 15 to 20 years older. The findings persisted after adjusting for smoking.

CONCLUSION

Multimorbidity increases with age but in patients carrying the diagnosis of COPD, these comorbidities are seen at an earlier age.

Multimorbidity and immigrant status: associations with area of origin and length of residence in host country

AIM

Multimorbidity is a growing phenomenon in primary care, and knowledge of the influence of social determinants on its evolution is vital. The aim of this study was to understand the relationship between multimorbidity and immigration, taking into account length of residence in the host country and area of origin of the immigrant population.

METHODS

Cross-sectional retrospective study of all adult patients registered within the public health service of Aragon, Spain (N = 1092279; 144238 were foreign-born), based on data from the EpiChron Cohort. Age-standardized prevalence rates of multimorbidity were calculated. Different models of binary logistic regressions were conducted to study the association between multimorbidity, immigrant status and length of residence in the host country.

RESULTS

The risk of multimorbidity in foreign-borns was lower than that of native-borns [odds ratio (OR): 0.54, 95% confidence interval (CI): 0.53-0.55]. The probability of experiencing multimorbidity was lowest for Asians (OR: 0.34, 95% CI: 0.31-0.37) and Eastern Europeans (OR: 0.42, 95% CI: 0.40-0.43), and highest for Latin Americans (OR: 0.70, 95% CI: 0.68-0.72). Foreign-born immigrants residing in Aragon for ≥5 years had a higher multimorbidity risk than those residing for <5 years (OR: 2.3, 95% CI: 2.2-2.4).

CONCLUSION

Prevalence of multimorbidity is lower among foreign-borns as compared with native-borns, but increases rapidly with length of residence in the host country. However, the progressive development of multimorbidity among immigrants varies widely depending on area of origin. These findings provide important insight into the health care needs of specific population groups and may help minimize the negative impact of multimorbidity among the most vulnerable groups.

Assessing and Measuring Chronic Multimorbidity in the Older Population: A Proposal for Its Operationalization

Background

Although the definition of multimorbidity as “the simultaneous presence of two or more chronic diseases” is well established, its operationalization is not yet agreed. This study aims to provide a clinically driven comprehensive list of chronic conditions to be included when measuring multimorbidity.

Methods

Based on a consensus definition of chronic disease, all four-digit level codes from the International Classification of Diseases, 10th revision (ICD-10) were classified as chronic or not by an international and multidisciplinary team. Chronic ICD-10 codes were subsequently grouped into broader categories according to clinical criteria. Last, we showed proof of concept by applying the classification to older adults from the Swedish National study of Aging and Care in Kungsholmen (SNAC-K) using also inpatient data from the Swedish National Patient Register.

Results

A disease or condition was considered to be chronic if it had a prolonged duration and either (a) left residual disability or worsening quality of life or (b) required a long period of care, treatment, or rehabilitation. After applying this definition in relation to populations of older adults, 918 chronic ICD-10 codes were identified and grouped into 60 chronic disease categories. In SNAC-K, 88.6% had ≥2 of these 60 disease categories, 73.2% had ≥3, and 55.8% had ≥4.

Conclusions

This operational measure of multimorbidity, which can be implemented using either or both clinical and administrative data, may facilitate its monitoring and international comparison. Once validated, it may enable the advancement and evolution of conceptual and theoretical aspects of multimorbidity that will eventually lead to better care.

Multimorbidity care model: Recommendations from the consensus meeting of the Joint Action on Chronic Diseases and Promoting Healthy Ageing across the Life Cycle (JA-CHRODIS)

Patients with multimorbidity have complex health needs but, due to the current traditional disease-oriented approach, they face a highly fragmented form of care that leads to inefficient, ineffective, and possibly harmful clinical interventions. There is limited evidence on available integrated and multidimensional care pathways for multimorbid patients. An expert consensus meeting was held to develop a framework for care of multimorbid patients that can be applied across Europe, within a project funded by the European Union; the Joint Action on Chronic Diseases and Promoting Healthy Ageing across the Life Cycle (JA-CHRODIS). The experts included a diverse group representing care providers and patients, and included general practitioners, family medicine physicians, neurologists, geriatricians, internists, cardiologists, endocrinologists, diabetologists, epidemiologists, psychologists, and representatives from patient organizations. Sixteen components across five domains were identified (Delivery of Care; Decision Support; Self Management Support; Information Systems and Technology; and Social and Community Resources). The description and aim of each component are described in these guidelines, along with a summary of key characteristics and relevance to multimorbid patients. Due to the lack of evidence-based recommendations specific to multimorbid patients, this care model needs to be assessed and validated in different European settings to examine specifically how multimorbid patients will benefit from this care model, and whether certain components have more importance than others.

Effectiveness of an intervention for improving drug prescription in primary care patients with multimorbidity and polypharmacy: study protocol of a cluster randomized clinical trial (Multi-PAP project)

Background

Multimorbidity is associated with negative effects both on people’s health and on healthcare systems. A key problem linked to multimorbidity is polypharmacy, which in turn is associated with increased risk of partly preventable adverse effects, including mortality. The Ariadne principles describe a model of care based on a thorough assessment of diseases, treatments (and potential interactions), clinical status, context and preferences of patients with multimorbidity, with the aim of prioritizing and sharing realistic treatment goals that guide an individualized management. The aim of this study is to evaluate the effectiveness of a complex intervention that implements the Ariadne principles in a population of young-old patients with multimorbidity and polypharmacy. The intervention seeks to improve the appropriateness of prescribing in primary care (PC), as measured by the medication appropriateness index (MAI) score at 6 and 12 months, as compared with usual care.

Methods/Design

Design: pragmatic cluster randomized clinical trial. Unit of randomization: family physician (FP). Unit of analysis: patient. Scope: PC health centres in three autonomous communities: Aragon, Madrid, and Andalusia (Spain). Population: patients aged 65–74 years with multimorbidity (≥3 chronic diseases) and polypharmacy (≥5 drugs prescribed in ≥3 months). Sample size: n = 400 (200 per study arm). Intervention: complex intervention based on the implementation of the Ariadne principles with two components: (1) FP training and (2) FP-patient interview. Outcomes: MAI score, health services use, quality of life (Euroqol 5D-5L), pharmacotherapy and adherence to treatment (Morisky-Green, Haynes-Sackett), and clinical and socio-demographic variables. Statistical analysis: primary outcome is the difference in MAI score between T0 and T1 and corresponding 95% confidence interval. Adjustment for confounding factors will be performed by multilevel analysis. All analyses will be carried out in accordance with the intention-to-treat principle.

Discussion

It is essential to provide evidence concerning interventions on PC patients with polypharmacy and multimorbidity, conducted in the context of routine clinical practice, and involving young-old patients with significant potential for preventing negative health outcomes.

Trial registration

Clinicaltrials.gov, NCT02866799

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-017-0584-x) contains supplementary material, which is available to authorized users.

[Multimorbidity in general practice and the Ariadne principles. A person-centred approach]

La multimorbilidad, definida como la presencia de dos o más enfermedades crónicas en un mismo individuo, conlleva consecuencias negativas para la persona e importantes retos para los sistemas sanitarios. En atención primaria, donde recae esencialmente la atención de este grupo de pacientes, la consulta es más compleja que la de un paciente con una única enfermedad debido, entre otros, al hecho de tener que manejar mayor cantidad de información clínica, disponer de poca evidencia científica para abordar la multimorbilidad, y tener que coordinar la labor de múltiples profesionales para garantizar la continuidad asistencial. Además, para poder implementar correctamente los planes de tratamiento en estos pacientes es necesario un proceso de toma de decisiones compartida médico-paciente. Entre las distintas herramientas disponibles para apoyar dicho proceso, recientemente se ha desarrollado una dirigida específicamente a pacientes con multimorbilidad en atención primaria y que se describe en el presente artículo: los principios Ariadne.