Patterns of comorbidity and the use of health services in the Dutch population

Equity in health service utilisation among middle-aged and elderly people with multiple chronic conditions in China: evidence from longitudinal data of 2011-2018 CHARLS

OBJECTIVES

Equity in health service utilisation is a central objective for health systems. Middle-aged and elderly patients with multiple chronic conditions (MCCs) are particularly vulnerable to healthcare inequity. This study aimed to update the information on the trends in the incidence and equity of outpatient health service utilisation (OHSU) and inpatient health service utilisation (IHSU) for middle-aged and elderly MCCs patients in China, identify socioeconomic determinants that may contribute to inequity, and suggest optimisation strategies to mitigate this disparity.

METHODS

Panel data obtained from four waves of the China Health and Retirement Longitudinal Study (CHARLS) were used to determine the trends in OHSU and IHSU. The inequity in OHSU and IHSU was measured by the Concentration Index (CI) and Horizontal Inequity Index (HI), which is a valid measure of health service utilisation equity. The decomposition model of the CI was set up to explore the contribution of various determinants of overall equity.

RESULTS

The annual rate of OHSU gradually decreased from 29.32% in 2011 to 27.27% in 2018. The HI remained positive and decreased from 0.0803 in 2011 to 0.0662 in 2018, indicating the existence of pro-rich inequity. The annual rate of IHSU gradually increased from 13.31% in 2011 to 19.89% in 2018. The HI remained positive and showed a declining trend from 0.2363 in 2011 to 0.0574 in 2018, evidencing pro-rich inequity; however, a trend towards the easing of inequity was observed.

CONCLUSIONS

Pro-rich inequity was present in both OHSU and IHSU among middle-aged and elderly MCCs patients in China. Economic status, area, education and age were the main contributors to pro-rich inequity. Concerted efforts are needed to allocate resources for mitigating health service utilisation inequity in middle-aged and elderly people with MCCs.

The Effect of Multimorbidity Patterns and the Impact of Comorbid Anxiety and Depression on Primary Health Service Use: The Men Androgen Inflammation Lifestyle Environment and Stress (MAILES) Study

This study sought to determine patterns of multimorbidity and quantify their impact on use of primary health services in the presence and absence of anxiety and depression among a cohort of urban community-dwelling men in Australia. The analytic sample consisted of men (n = 2039; age 38–85) from the follow-up wave of a prospective cohort study of all participants of the Florey Adelaide Male Ageing Study (FAMAS; Stage 2 [2007–2010]) and age-matched men from the North-West Adelaide Health Study (NWAHS; Stage 3 [2008–2010]). Self-reported data and linkage with a national universal health coverage scheme (Medicare) provided information on the prevalence of eight chronic conditions and health service utilization information (including annual GP visits). Obesity and cardiovascular disease (CVD) were associated with the highest number of comorbid conditions. Two nonrandom multimorbidity “clusters” emerged: “CVD, Obesity, Diabetes” and “CVD, Obesity, Osteoarthritis.” Participants with conditions comorbid with CVD were more likely to have 10 or more annual GP visits, compared to multimorbidity involving other conditions. In comparison to participants without CVD, the presence of CVD increased the chance of having 10 or more annual GP visits (adjusted risk ratio: 3.7; 95% CI [2.8, 4.8]). When CVD was comorbid with anxiety and depression, having 10 or more annual GP visits was more common (adjusted risk ratio: 1.8; 95% CI [1.2, 2.5]). Multimorbidity patterns involving CVD, especially for multimorbidity that includes CVD with comorbid anxiety and depression, should be considered in developing clinical trials to better inform medical decision-making and care for patients with CVD and comorbid conditions.

Health-Related Quality of Life and Associated Factors Among Type Two Diabetic Patients on Follow-Up in Dessie Comprehensive Specialized Hospital, Dessie, North East Ethiopia, 2020

BACKGROUND

Diabetes mellitus is a disorder of carbohydrate metabolism and it is highly related with diminished HRQOL in Ethiopia; diabetic related complications especially bring major negative impacts on HRQOL.

OBJECTIVE

To assess HRQOL and associated factors among type two diabetic patients in Dessie Comprehensive Specialized Hospital, north east Ethiopia, 2020.

METHODS

Institutional-based cross-sectional study design was conducted on 417 patients through systematic random sampling technique from February 08 to April 08, 2020. WHO HRQOL 26 items were used to measure outcome variable. Face-to-face interview, document review and measurement were implemented to collect data. The data were analyzed by IBM SPSS Statistics version 25 and summarized by using tables. Simple linear regression analysis was done and forwarded to multivariable linear regression analysis at p-value <0.25. Next multivariable linear regression analysis was done and variables whose p-value less than 0.05 with unstandardized B-coefficient were declared significant predictor variables.

RESULTS

The mean scores of physical domain, psychological domain, environmental domain and social domain were 48±6.7 (47-49), 52±4.2 (50-52.3), 48.9±3.4 (48-50.4) and 49±4 (48-50), respectively. As age increased by one year, patients' physical HRQOL decreased by 0.031 factor, keeping effect of other variables constant [-0.031, 95% CI (-0.050 to-0.013)]. As duration of diabetes increased by one year, patients' physical HRQOL increased by 0.034 factor, keeping effect of other variables constant [0.034, 95% CI (0.004 to 0.065)]. In general, age, depression, perceived social stigma, self-employed, having two complications, widowed, insulin and oral anti-diabetic medication affected HRQOL negatively and duration of diabetes in physical domain and university level of education in environmental domain affected HRQOL positively.

CONCLUSION AND RECOMMENDATION

The mean score of health-related quality of life in physical health domain, psychological health domain, social health domain and environmental health domain was recorded nearly half score point out of a hundred. Health professionals should follow a holistic approach to management to address negatively associated predictor variables with HRQOL.

Patterns of patients with multiple chronic conditions in primary care: A cross-sectional study

Objective

Our aim was to identify the patterns of multimorbidity among a group of patients who visited primary care in Singapore.

Methods

A cross-sectional study of electronic medical records was conducted on 437,849 individuals aged 0–99 years who visited National Healthcare Group Polyclinics from 1 Jul 2015 to 30 Jun 2016 for the management of chronic conditions. Patients’ health conditions were coded with the 10^th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10), and patient records were extracted for analysis. Patients’ diagnosis codes were grouped by exploratory factor analysis (EFA), and patterns of multimorbidity were then identified by latent class analysis (LCA).

Results

EFA identified 19 groups of chronic conditions. Patients with at least three chronic conditions were further separated into eight classes based on demographics and probabilities of various diagnoses. We found that older patients had higher probabilities of comorbid hypertension, kidney disease and ischaemic heart disease (IHD), while younger patients had a higher probability of comorbid obesity. Female patients had higher probabilities of comorbid arthritis and anaemia, while male patients had higher probabilities of comorbid kidney diseases and IHD. Indian patients presented with a higher probability of comorbid diabetes than Chinese and Malay patients.

Conclusions

This study demonstrated that patients with multimorbidity in primary care could be classified into eight patterns. This knowledge could be useful for more precise management of these patients in the multiethnic Asian population of Singapore. Programmes for early intervention for at-risk groups can be developed based on the findings.

Multimorbidity Patterns in the General Population: Results from the EpiChron Cohort Study

The correct management of patients with multimorbidity remains one of the main challenges for healthcare systems worldwide. In this study, we analyze the existence of multimorbidity patterns in the general population based on gender and age. We conducted a cross-sectional study of individuals of all ages from the EpiChron Cohort, Spain (1,253,292 subjects), and analyzed the presence of systematic associations among chronic disease diagnoses using exploratory factor analysis. We identified and clinically described a total of 14 different multimorbidity patterns (12 in women and 12 in men), with some relevant differences in the functions of age and gender. The number and complexity of the patterns was shown to increase with age in both genders. We identified associations of circulatory diseases with respiratory disorders, chronic musculoskeletal diseases with depression and anxiety, and a very consistent pattern of conditions whose co-occurrence is known as metabolic syndrome (hypertension, diabetes, obesity, and dyslipidaemia), among others. Our results demonstrate the potential of using real-world data to conduct large-scale epidemiological studies to assess the complex interactions among chronic conditions. This could be useful in designing clinical interventions for patients with multimorbidity, as well as recommendations for healthcare professionals on how to handle these types of patients in clinical practice.

Multimorbidity, healthcare utilization and socioeconomic status: A register-based study in Denmark

Background

People with multimorbidity have reduced functional capacity, lower quality of life, higher mortality rates and use healthcare resources more intensively than healthy people or those with a single chronic condition. Multimorbidity was defined as the coexistence of two or more chronic conditions in the same person. The aim of this study was to explore associations between multimorbidity and use of healthcare services and the impact of socioeconomic status on utilization of hospitalizations and bed days.

Methods

The study population included all individuals aged 16 years and older who lived in the Capital Region of Denmark on January 1st, 2012. Data on chronic conditions, use of healthcare services and demographics were obtained from Danish national administrative and health registries. Zero-inflated models were used to calculate anticipated annual use of hospitalizations and bed days.

Findings

The study population comprised 1,397,173 individuals; the prevalence of multimorbidity was 22%. Prevalence was inversely related to educational attainment. For people with multimorbidity, utilization of hospitalizations and bed days increased approximately linearly with the number of chronic conditions. However, a steep increase in utilization of bed days was observed between five and six or more chronic conditions. An educational gradient in hospitalization rates and use of bed days was observed regardless of the number of chronic conditions. Educational attainment was strongly associated with healthcare utilization.

Conclusion

Multimorbidity was associated with a significant increase in utilization of all healthcare services in Denmark. In addition, a socioeconomic gradient was observed in utilization of hospitalizations and bed days.

Patterns of multimorbid health conditions: a systematic review of analytical methods and comparison analysis

Background

The latest review of studies on multimorbidity patterns showed high heterogeneity in the methodology for identifying groups of multimorbid conditions. However, it is unclear how analytical methods used influence the identified multimorbidity patterns.

Methods

We undertook a systematic review of analytical methods used to identify multimorbidity patterns in PubMed and EMBASE from their inception to January 2017. We conducted a comparison analysis to assess the effect the analytical methods had on the multimorbidity patterns identified, using the Australian National Health Survey (NHS) 2007-08 data.

Results

We identified 13 194 studies and excluded 13 091 based on titles/abstracts. From the full-text reviews of the 103 remaining publications, we identified 41 studies that used five different analytical methods to identify multimorbid conditions in the studies. Thirty-seven studies (90%) adopted either the factor-analysis or hierarchical-clustering methods, but heterogeneity arises for the use of different proximity measures within each method to form clusters. Our comparison analysis showed the variation in identified groups of multimorbid conditions when applying the methods to the same NHS data. We extracted main similarities among the groupings obtained by the five methods: (i) cardiovascular and metabolic diseases, (ii) mental health problems and (iii) allergic diseases.

Conclusion

We showed the extent of effects for heterogeneous analytical methods on identification of multimorbidity patterns. However, more work is needed to guide investigators for choosing the best analytical method to improve the validity and generalizability of findings. Investigators should also attempt to compare results obtained by various methods for a consensus grouping of multimorbid conditions.

Does Health Care Utilization Before Hip Arthroscopy Predict Health Care Utilization After Surgery in the US Military Health System? An Investigation Into Health-Seeking Behavior

BACKGROUND

The influence of prior patterns of health care utilization on future health care utilization has had minimal investigation in populations with musculoskeletal disorders.

OBJECTIVES

The purpose of this study was to explore the relationship between presurgical health care utilization and postsurgical health care utilization in a population of patients undergoing hip surgery in the US Military Health System.

METHODS

In this observational cohort study, person-level data were collected for patients undergoing hip arthroscopy in the Military Health System from 2003 to 2015, capturing all encounters 12 months before and 24 months after surgery for every individual. Cluster analysis was used to categorize individuals with high and low health care utilization, based on preoperative health care visits. Unadjusted and adjusted Poisson and generalized linear models were generated. Health care utilization outcomes were targeted, including costs, visits, and medication use.

RESULTS

There were 1850 individuals in the final cohort (mean age, 32.18 years; 55.4% male). The high health care utilization group averaged 57.69 ± 25.87 visits, compared to 20.43 ± 8.36 visits in the low utilization group. There were significant differences between groups for total health care visits (58.17; 95% confidence interval [CI]: 57.39, 58.58), total health care costs ($11 539.71; 95% CI: $10 557.26, $12 595.04), hip-related visits (12.77; 95% CI: 12.59, 12.96), hip-related costs ($3325.07; 95% CI: $2886.43, $3804.51), days' supply of pain medications (752.67; 95% CI: 751.24, 754.11), opioid prescriptions (48.83; 95% CI: 48.47, 49.21), and cost of pain medications ($1074.80; 95% CI: $1011.91, $1137.68).

CONCLUSION

Presurgical patterns of health care utilization were associated with postsurgical patterns of health care utilization, indicating that those patients who used more care before surgery also used more care after surgery. Clinicians should consider prior patterns of health care utilization, including utilization unrelated to the index condition, when determining care plans and prognosis. J Orthop Sports Phys Ther 2018;48(11):878-886. Epub22 Jul 2018. doi:10.2519/jospt.2018.8259.

More frequent use of health care services among distressed compared with nondistressed survivors of lymphoma and chronic lymphocytic leukemia: Results from the population-based PROFILES registry

BACKGROUND

Follow-up care for a growing population of survivors of lymphoma and chronic lymphocytic leukemia (CLL) together with the adverse effects these survivors may experience as a result of their cancer and treatment have led to more pressure being placed on health care services. The objectives of the current study were to: 1) compare the use of medical care services by survivors with that of a normative population; 2) evaluate the use of medical and psychosocial care services among distressed and nondistressed survivors; and 3) identify associated sociodemographic and clinical factors.

METHODS

Survivors of lymphoma and CLL diagnosed between 1999 and 2012 were selected via the population-based Netherlands Cancer Registry and completed the Hospital Anxiety and Depression Scale questionnaire and questions regarding health care. Outcomes were compared with an age-matched and sex-matched normative population.

RESULTS

A total of 1444 survivors responded (69%). Survivors of lymphoma and CLL contacted their general practitioner (3.8 vs 2.3; P<.001) and medical specialist (5.7 vs 1.6; P<.001) more often within the last year compared with a normative population. In addition, psychologically distressed survivors had even more medical contacts and received psychosocial care more often compared with nondistressed survivors. In addition to psychological distress, comorbidity, female sex, and older age were found to be associated with a greater use of medical services, whereas younger age was associated with receiving psychosocial care.

CONCLUSIONS

Survivors of lymphoma and CLL, especially those who are psychologically distressed, report an increased use of health care services compared with a normative population. Further studies are needed to explore whether the use of widely applicable psychosocial interventions could reduce the frequency of medical contacts. Cancer 2018;124:3016-24. © 2018 Netherlands Comprehensive Cancer Organisation. Cancer published by Wiley Periodicals, Inc. on behalf of American Cancer Society.

Association between perceived stress, multimorbidity and primary care health services: a Danish population-based cohort study

OBJECTIVES

Mental stress is common in the general population. Mounting evidence suggests that mental stress is associated with multimorbidity, suboptimal care and increased mortality. Delivering healthcare in a biopsychosocial context is key for general practitioners (GPs), but it remains unclear how persons with high levels of perceived stress are managed in primary care. We aimed to describe the association between perceived stress and primary care services by focusing on mental health-related activities and markers of elective/acute care while accounting for mental-physical multimorbidity.

DESIGN

Population-based cohort study.

SETTING

Primary healthcare in Denmark.

PARTICIPANTS

118 410 participants from the Danish National Health Survey 2010 followed for 1 year. Information on perceived stress and lifestyle was obtained from a survey questionnaire. Information on multimorbidity was obtained from health registers.

OUTCOME MEASURES

General daytime consultations, out-of-hours services, mental health-related services and chronic care services in primary care obtained from health registers.

RESULTS

Perceived stress levels were associated with primary care activity in a dose-response relation when adjusted for underlying conditions, lifestyle and socioeconomic factors. In the highest stress quintile, 6.8% attended GP talk therapy (highest vs lowest quintile, adjusted incidence rate ratios (IRR): 4.96, 95% CI 4.20 to 5.86), 3.3% consulted a psychologist (IRR: 6.49, 95% CI 4.90 to 8.58), 21.5% redeemed an antidepressant prescription (IRR: 4.62, 95% CI 4.03 to 5.31), 23.8% attended annual chronic care consultations (IRR: 1.22, 95% CI 1.16 to 1.29) and 26.1% used out-of-hours services (IRR: 1.47, 95% CI 1.51 to 1.68). For those with multimorbidity, stress was associated with more out-of-hours services, but not with more chronic care services.

CONCLUSION

Persons with high stress levels generally had higher use of primary healthcare, 4-6 times higher use of mental health-related services (most often in the form of psychotropic drug prescriptions), but less timely use of chronic care services.

Epilepsy as a systemic condition: Link with somatic comorbidities

BACKGROUND

People with epilepsy have more concomitant medical conditions than the general population; these comorbidities play an important role in premature mortality. We sought to generate explanatory hypotheses about the co-occurrence of somatic comorbidities and epilepsy, avoiding causal and treatment-resultant biases.

METHODS

We collected clinical, demographic and somatic comorbidity data for 2016 consecutive adults with epilepsy undergoing assessment at a tertiary centre and in 1278 people with epilepsy in the community. Underlying causes of epilepsy were not classed as comorbidities.

RESULTS

Somatic comorbidities were more frequent in the referral centre (49%) where people more frequently had active epilepsy than in the community (36%). Consistent risk factors for comorbidities were found in both cohorts. Using multivariable ordinal regression adjusted for age, longer epilepsy duration and an underlying brain lesion were independently associated with a smaller burden of somatic conditions. The treatment burden, measured by the number of drugs to which people were exposed, was not an independent predictor. Shorter epilepsy duration was a predictor for conditions that conceivably harbour significant mortality risks.

CONCLUSIONS

Somatic comorbidities do not occur randomly in relation to epilepsy; having more severe epilepsy seems to be a risk factor. Independently from age, the early period after epilepsy onset appears to be at particular risk, although it is not clear whether this relates to an early mortality or to a later decrease in the burden of comorbidities. These results suggest that, for some people, epilepsy should be considered a systemic condition not limited to the CNS.

Use of medical services and medicines attributable to type 2 diabetes care in Yaoundé, Cameroon: a cross-sectional study

Background

The increasing numbers of people with type 2 diabetes (T2D) is a global concern and especially in sub-Saharan Africa, where diabetes must compete for resources with communicable diseases. Diabetes intensifies health care utilisation and leads to an increase in medical care costs. However, In Cameroon like in most developing countries, data on the impact of diabetes on the medical health system are scarce. We aimed to analyse the use of medical services and medicines attributable to T2D care in Yaoundé, Cameroon.

Methods

We conducted a cross-sectional study comparing the use of medical services and medicines on 500 people with T2D attending the diabetic outpatient units of three hospitals in Yaoundé and 500 people without diabetes matched for age, sex and residence. We performed multivariate logistic and quantile regressions to assess the effect of diabetes on the use of medical services and medicines and the presence of other chronic health problems. Models were adjusted for age, educational level, marital status, occupation and family income.

Results

Overall, the rate of use of health services was found to be greater in people with T2D than those without diabetes. People with T2D had greater odds of having an outpatient visit to any clinician (OR 97.1 [95% CI: 41.6–226.2]), to be hospitalised (OR 11.9 [95% CI: 1.6–87.9]), to take at least one medicine (OR 83.1 [37.1–185.8]) compared with people without diabetes. We also observed an association between diabetes and some chronic diseases/diabetes complications including hypertension (OR 9.2 [95% CI: 5.0–16.9]), cardiovascular diseases (OR 1.9 [95% CI: 0.8–4.9]), peripheral neuropathy (OR 6.2 [95% CI: 3.4–11.2]), and erectile dysfunction (OR 5.8 [95% CI: 2.7–12.1]).

Conclusions

This study showed that the presence of diabetes is associated with an increased use of health care services and medicines as well as with some chronic diseases/diabetes complications.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2197-0) contains supplementary material, which is available to authorized users.

Do We Reap What We Sow? Exploring the Association between the Strength of European Primary Healthcare Systems and Inequity in Unmet Need

Access to healthcare is inequitably distributed across different socioeconomic groups. Several vulnerable groups experience barriers in accessing healthcare, compared to their more wealthier counterparts. In response to this, many countries use resources to strengthen their primary care (PC) system, because in many European countries PC is the first entry-point to the healthcare system and plays a central role in the coordination of patients through the healthcare system. However it is unclear whether this strengthening of PC leads to less inequity in access to the whole healthcare system. This study investigates the association between strength indicators of PC and inequity in unmet need by merging data from the European Union Statistics on Income and Living Conditions database (2013) and the Primary Healthcare Activity Monitor for Europe (2010). The analyses reveal a significant association between the Gini coefficient for income inequality and inequity in unmet need. When the Gini coefficient of a country is one SD higher, the social inequity in unmet need in that particular country will be 4.960 higher. Furthermore, the accessibility and the workforce development of a country's PC system is inverse associated with the social inequity of unmet need. More specifically, when the access- and workforce development indicator of a country PC system are one standard deviation higher, the inequity in unmet healthcare needs are respectively 2.200 and 4.951 lower. Therefore, policymakers should focus on reducing income inequality to tackle inequity in access, and strengthen PC (by increasing accessibility and better-developing its workforce) as this can influence inequity in unmet need.

Health-care utilization by prognosis profile in a managed care setting: using the Surveillance, Epidemiology and End Results Cancer Survival Calculator SEER*CSC

BACKGROUND

Accurate estimation of the probability of dying of cancer versus other causes is needed to inform goals of care for cancer patients. Further, prognosis may also influence health-care utilization. This paper describes health service utilization patterns of subgroups of prostate cancer and colorectal cancer (CRC) patients with different relative probabilities of dying of their cancer or other conditions.

METHODS

A retrospective cohort of cancer patients from Kaiser Permanente Colorado were divided into three groups using the predicted probabilities of dying of cancer and other causes calculated by the nomograms in the National Cancer Institute Surveillance, Epidemiology and End Results Cancer Survival Calculator. Demographic, disease-related characteristics, and health service utilization patterns were described across subgroups.

RESULTS

The cohort consisted of 2092 patients (1102 prostate cancer and 990 CRC). A new diagnosis of cancer increased utilization of cancer-related services with rates as high as 9.1/1000 person-days for prostate cancer and 36.2/1000 person-days for CRC. Little change was observed in the number of primary and other specialty care visits from prediagnosis to 1 and 2 years postdiagnosis.

CONCLUSIONS

We found that although a new diagnosis of cancer increased utilization of cancer-related services for an extended time period, the timing of cancer diagnosis did not appear to affect other types of utilization. Future research should assess the reason for the lack of impact of cancer and unrelated comorbid conditions on utilization and whether desired outcomes of care were achieved.

A systematic review protocol for measuring comorbidity in inpatient rehabilitation for non-traumatic brain injury

BACKGROUND

Comorbidity can affect health-care utilization and outcomes, and the results and interpretation of risk adjustment studies that attempt to predict rehabilitation utilization and outcomes are influenced by the choice of comorbidity measurement. Although the identification of an appropriate measurement has been conducted in some populations and outcomes, this information is currently lacking for the non-traumatic brain injury (nTBI) population in inpatient rehabilitation settings. As such, this is a systematic review protocol to survey the methods used to measure comorbidities in the rehabilitation setting for patients with nTBI.

METHODS/DESIGN

MEDLINE, MEDLINE In-Process, Embase, The Cochrane Database of Systematic Reviews, PsycINFO, and Health and Psychosocial Instruments will be systematically searched using the concepts 'nTBI,' 'comorbidity,' and 'rehabilitation.' Grey matters and the reference list of eligible articles will also be searched. Study selection will be performed independently by two reviewers based on predetermined eligibility criteria through two rounds of screening using, first, the title and abstract, followed by full-text. Extracted information will include study purpose, design, and setting; data source and type; outcomes variables; statistical methods; comorbidity measurement method, rationale, justification, or validation; and results involving comorbidity. The data will be tabulated and narratively synthesized. Meta-analyses will be performed if appropriate.

SYSTEMATIC REVIEW REGISTRATION

This protocol has not been registered with PROSPERO.

DISCUSSION

This protocol provides a systematic method for surveying current practice as well as monitoring the progress on comorbidity measurement methodology and effects of comorbidity on rehabilitation outcomes for patients with nTBI. The selection of an appropriate comorbidity measurement method has implications for the interpretation of both descriptive and risk adjustment studies, and thus, the validity of evidence used to inform planning and delivery of services.

Applying multivariate clustering techniques to health data: the 4 types of healthcare utilization in the Paris metropolitan area

BACKGROUND

Cost containment policies and the need to satisfy patients' health needs and care expectations provide major challenges to healthcare systems. Identification of homogeneous groups in terms of healthcare utilisation could lead to a better understanding of how to adjust healthcare provision to society and patient needs.

METHODS

This study used data from the third wave of the SIRS cohort study, a representative, population-based, socio-epidemiological study set up in 2005 in the Paris metropolitan area, France. The data were analysed using a cross-sectional design. In 2010, 3000 individuals were interviewed in their homes. Non-conventional multivariate clustering techniques were used to determine homogeneous user groups in data. Multinomial models assessed a wide range of potential associations between user characteristics and their pattern of healthcare utilisation.

RESULTS

We identified four distinct patterns of healthcare use. Patterns of consumption and the socio-demographic characteristics of users differed qualitatively and quantitatively between these four profiles. Extensive and intensive use by older, wealthier and unhealthier people contrasted with narrow and parsimonious use by younger, socially deprived people and immigrants. Rare, intermittent use by young healthy men contrasted with regular targeted use by healthy and wealthy women.

CONCLUSION

The use of an original technique of massive multivariate analysis allowed us to characterise different types of healthcare users, both in terms of resource utilisation and socio-demographic variables. This method would merit replication in different populations and healthcare systems.

Outcomes of HIV-infected patients receiving care at multiple clinics

Receiving care at multiple clinics may compromise the therapeutic patient-provider alliance and adversely affect the treatment of people living with HIV. We evaluated 12,759 HIV-infected adults in Philadelphia, PA between 2008 and 2010 to determine the effects of using multiple clinics for primary HIV care. Using generalized estimating equations with logistic regression, we examined the relationship between receiving care at multiple clinics (≥ 1 visit to two or more clinics during a calendar year) and two outcomes: (1) use of ART and (2) HIV viral load ≤ 200 copies/mL for patients on ART. Overall, 986 patients (8 %) received care at multiple clinics. The likelihood of attending multiple clinics was greater for younger patients, women, blacks, persons with public insurance, and for individuals in their first year of care. Adjusting for sociodemographic factors, patients receiving care at multiple clinics were less likely to use ART (AOR = 0.62, 95 % CI 0.55-0.71) and achieve HIV viral suppression (AOR = 0.78, 95 % CI 0.66-0.94) than individuals using one clinic. Qualitative data are needed to understand the reasons for visiting multiple clinics.

Distinct trajectories of multimorbidity in primary care were identified using latent class growth analysis

Objectives

To investigate the use of latent class growth analysis (LCGA) in understanding onset and changes in multimorbidity over time in older adults.

Study Design and Setting

This study used primary care consultations for 42 consensus-defined chronic morbidities over 3 years (2003–2005) by 24,615 people aged >50 years at 10 UK general practices, which contribute to the Consultations in Primary Care Archive database. Distinct groups of people who had similar progression of multimorbidity over time were identified using LCGA. These derived trajectories were tested in another primary care consultation data set with linked self-reported health status.

Results

Five clusters of people representing different trajectories were identified: those who had no recorded chronic problems (40%), those who developed a first chronic morbidity over 3 years (10%), a developing multimorbidity group (37%), a group with increasing number of chronic morbidities (12%), and a multi-chronic group with many chronic morbidities (1%). These trajectories were also identified using another consultation database and associated with self-reported physical and mental health.

Conclusion

There are distinct trajectories in the development of multimorbidity in primary care populations, which are associated with poor health. Future research needs to incorporate such trajectories when assessing progression of disease and deterioration of health.

[Development of clinical practice guidelines for patients with comorbidity and multiple diseases]

La atención a pacientes con comorbilidad y pluripatología supone un reto para cualquier sistema sanitario. Las guías de práctica clínica (GPC) presentan limitaciones cuando se aplican a esta población. El objetivo de este trabajo es realizar una propuesta terminológica y metodológica sobre el abordaje de la comorbilidad y la pluripatología en las GPC. De acuerdo a la revisión bibliográfica efectuada, se sugieren algunas propuestas para su abordaje en las diferentes fases de elaboración de las GPC, con especial atención a la inclusión de los clusters de comorbilidad en las preguntas clínicas iniciales, la incorporación de la evidencia indirecta, el peso de la carga de gestionar la enfermedad para el paciente y su entorno en la formulación de recomendaciones, así como las estrategias de difusión e implementación. Estas propuestas deben desarrollarse en mayor profundidad con la participación de más agentes para disponer de herramientas válidas y útiles en esta población.

Development of clinical practice guidelines for patients with comorbidity and multiple diseases

The management of patients with comorbidity and polypathology represents a challenge for all healthcare systems. Clinical practice guidelines (CPGs) have limitations when applied to this population. The aim of this study is to propose the terminology and methodology for optimally approach comorbidity and polypathology in the CPGs. Based on a literature review, we suggest a number of proposals for the approach in different phases of CPG preparation, with special attention to the inclusion of clusters of comorbidity in the initial questions the implementation of indirect evidence, the burden of disease management for patients and their environment, when establishing recommendations, as well as the strategies of dissemination and implementation. These proposals should be developed in greater depth with the implication of more agents in order to have valid and useful tools for this population.

Direct access to physical therapy for patients with low back pain in the Netherlands: prevalence and predictors

BACKGROUND

In the Netherlands, direct access to physical therapy was introduced in 2006. Although many patients with back pain visit physical therapists through direct access, the frequency and characteristics of episodes of care are unknown.

OBJECTIVE

The purposes of this study were: (1) to investigate the prevalence of direct access to physical therapy for patients with low back pain in the Netherlands from 2006 to 2009, (2) to examine associations between mode of access (direct versus referral) and patient characteristics, and (3) to describe the severity of the back complaints at the beginning and end of treatment for direct access and referral-based physical therapy.

DESIGN

A cross-sectional study was conducted using registration data of physical therapists obtained from a longitudinal study.

METHOD

Data were used from the National Information Service for Allied Health Care, a registration network of Dutch physical therapists. Mode of access (direct or referral) was registered for each episode of physical therapy care due to back pain from 2006 to 2009. Logistic regression analysis was used to explore associations between mode of access and patient/clinical characteristics.

RESULTS

The percentage of episodes of care for which patients with back pain directly accessed a physical therapist increased from 28.9% in 2006 to 52.1% in 2009. Characteristics associated with direct access were: middle or higher education level (odds ratio [OR]=1.3 and 2.0, respectively), previous physical therapy care (OR=1.7), recurrent back pain (OR=1.7), duration of back pain <7 days (OR=4.2), and age >55 years (OR=0.6).

LIMITATIONS

The study could not compare outcomes of physical therapy care by mode of access because this information was not registered from the beginning of data collection and, therefore, was missing for too many cases.

CONCLUSIONS

Direct access was used for an increasing percentage of episodes of physical therapy care in the years 2006 to 2009. Patient/clinical characteristics associated with the mode of access were education level, recurrent back pain, previous physical therapy sessions, and age.

Characteristics of older patients with back pain in general practice: BACE cohort study

BACKGROUND

Although back pain is common among older people, limited information is available about the characteristics of these patients in primary care. Earlier research suggests that the severity of back symptoms increases with older age.

METHODS

Patients aged >55 years visiting a general practitioner with a new episode of back pain were included in the BACE study. Information on patients' characteristics, characteristics of the complaint and physical examination were derived from the baseline measurement. Cross-sectional differences between patients aged >55-74 and ≥75 years were analysed using an unpaired t-test, Mann-Whitney U-test or a chi-square test.

RESULTS

A total of 675 back pain patients were included in the BACE study, with a median age of 65 (interquartile range 60-71) years. Patients aged >55-74 years had a mean disability score (measured with the Roland Disability Questionnaire) of 9.4 [standard deviation (SD) 5.8] compared with 12.1 (SD 5.5) in patients aged ≥75 years (p ≤ 0.01). The older group reported more additional musculoskeletal disorders and more often had low bone quality (based on ultrasound measurement of the heel) than patients aged >55-74 years. Average back pain severity over the previous week showed no difference (p = 0.11) between the age groups, but severity of back pain at the moment of filling in the questionnaire was higher (p = 0.03) in the older age group.

CONCLUSIONS

In this study, older back pain patients reported more disabilities and co-morbidity. However, the clinical relevance of these differences for the course of the back pain episode in older patients remains a subject for further research.

Prevalence of self-reported chronic diseases in individuals over the age of 40 in São Paulo, Brazil: the PLATINO study

Few studies have been conducted to determine the prevalence of chronic diseases and its impact in individuals aged 40 years or over in Brazil. The objective of this study is to evaluate the prevalence of some common chronic diseases in the Brazilian subgroup assessed by the PLATINO study using a self-reported survey. A total of 918 individuals (55% women) with a mean age of 54.6 ± 10.9 years were evaluated. The most prevalent diseases were obesity (62.5%), hypertension (39.2%) and gastritis (30.9%). We conclude from this study that there is a high prevalence of chronic diseases in the population over 40 years of age: 88% of the population suffers from a minimum of one disease and 26% of the sample suffers from at least three diseases. We also observed that the number of comorbidities increases with age.

Prevalence of depression and utilization of health care in single and multiple morbidity: a population-based cohort study

BACKGROUND

This study aimed to determine whether depression in patients with long-term conditions is associated with the number of morbidities or the type of co-morbidity. Method A cohort study of 299 912 participants aged 30-100 years. The prevalence of depression, rates of health-care utilization and costs were evaluated in relation to diagnoses of diabetes mellitus (DM), coronary heart disease (CHD), stroke and colorectal cancer.

RESULTS

The age-standardized prevalence of depression was 7% in men and 14% in women with no morbidity. The frequency of depression increased in single morbidities including DM (men 13%, women 22%), CHD (men 15%, women 24%), stroke (men 14%, women 26%) or colorectal cancer (men 10%, women 21%). Participants with concurrent diabetes, CHD and stroke had a very high prevalence of depression (men 23%, women 49%). The relative rate of depression for one morbidity was 1.63 [95% confidence interval (CI) 1.59-1.66], two morbidities 1.96 (95% CI 1.89-2.03) and three morbidities 2.35 (95% CI 2.03-2.59). Compared to those with no morbidity, depression was associated with higher rates of health-care utilization and increased costs at any level of morbidity. In women aged 55 to 64 years without morbidity, the mean annual health-care cost was £513 without depression and £1074 with depression; when three morbidities were present, the cost was £1495 without depression and £2878 with depression.

CONCLUSIONS

Depression prevalence and health-care costs are more strongly associated with the number of morbidities than the nature of the co-morbid diagnosis.

Co-occurrence of leading lifestyle-related chronic conditions among adults in the United States, 2002-2009

INTRODUCTION

Public health and clinical strategies for meeting the emerging challenges of multiple chronic conditions must address the high prevalence of lifestyle-related causes. Our objective was to assess prevalence and trends in the chronic conditions that are leading causes of disease and death among adults in the United States that are amenable to preventive lifestyle interventions.

METHODS

We used self-reported data from 196,240 adults aged 25 years or older who participated in the National Health Interview Surveys from 2002 to 2009. We included data on cardiovascular disease (coronary heart disease, angina pectoris, heart attack, and stroke), cancer, chronic obstructive pulmonary disease (emphysema and chronic bronchitis), diabetes, and arthritis.

RESULTS

In 2002, an unadjusted 63.6% of participants did not have any of the 5 chronic conditions we assessed; 23.9% had 1, 9.0% had 2, 2.9% had 3, and 0.7% had 4 or 5. By 2009, the distribution of co-occurrence of the 5 chronic conditions had shifted subtly but significantly. From 2002 to 2009, the age-adjusted percentage with 2 or more chronic conditions increased from 12.7% to 14.7% (P < .001), and the number of adults with 2 or more conditions increased from approximately 23.4 million to 30.9 million.

CONCLUSION

The prevalence of having 1 or more or 2 or more of the leading lifestyle-related chronic conditions increased steadily from 2002 to 2009. If these increases continue, particularly among younger adults, managing patients with multiple chronic conditions in the aging population will continue to challenge public health and clinical practice.

Consultations with complementary and alternative medicine practitioners by older Australians: results from a national survey

Background

The use of complementary and alternative medicines (CAM) and CAM practitioners is common, most frequently for the management of musculoskeletal conditions. Knowledge is limited about the use of CAM practitioners by older people, and specifically those with other long term or chronic conditions.

Methods

In 2011 we conducted an Australia wide survey targeting older adults aged over 50 years (n = 2540). Participants were asked to identify their chronic conditions, and from which health professionals they had ‘received advice or treatment from in the last 3 months’, including ‘complementary health practitioners, e.g. naturopath’. Descriptive analyses were undertaken using SPSS and STATA software.

Results

Overall, 8.8% of respondents reported seeing a CAM practitioner in the past three months, 12.1% of women and 3.9% of men; the vast majority also consulting medical practitioners in the same period. Respondents were more likely to report consulting a CAM practitioner if they had musculoskeletal conditions (osteoporosis, arthritis), pain, or depression/anxiety. Respondents with diabetes, hypertension and asthma were least likely to report consulting a CAM practitioner. Those over 80 reported lower use of CAM practitioners than younger respondents. CAM practitioner use in a general older population was not associated with the number of chronic conditions reported, or with the socio-economic level of residence of the respondent.

Conclusion

Substantial numbers of older Australians with chronic conditions seek advice from CAM practitioners, particularly those with pain related conditions, but less often with conditions where there are clear treatment guidelines using conventional medicine, such as with diabetes, hypertension and asthma. Given the policy emphasis on better coordination of care for people with chronic conditions, these findings point to the importance of communication and integration of health services and suggest that the concept of the ‘treating team’ needs a broad interpretation.

Course and prognosis of older back pain patients in general practice: a prospective cohort study

The aim of the current study was to determine the course of back pain in older patients and identify prognostic factors for non-recovery at 3 months' follow-up. We conducted a prospective cohort study (the BACE study) of patients aged >55 years visiting a general practitioner (GP) with a new episode of back pain in the Netherlands. The course of back pain was described in terms of self-perceived recovery, pain severity, disability, pain medication, and GP visits at 6 weeks' and 3 months' follow-up. Prognostic factors for non-recovery at 3 months' follow-up were derived from the baseline questionnaire and physical examination. Variables with a prognostic value were identified with multivariable logistic regression analysis (method backward), and an area under the receiver operating curve (AUC) was calculated for the prognostic model. A total of 675 back pain patients (mean age 66.4 (SD 7.6) years) participated in the BACE cohort study. At 6 weeks' follow-up 64% of the patients reported non-recovery from back pain. At 3 months' follow-up 61% still reported non-recovery, but only 26% of these patients had revisited the GP. Longer duration of the back pain, severity of back pain, history of back pain, absence of radiating pain in the leg below the knee, number of comorbidities, patients' expectation of non-recovery, and a longer duration of the timed 'Up and Go' test were significantly associated with non-recovery in a multiple regression model (AUC 0.79). This information can help GPs identify older back pain patients at risk for non-recovery.

Insulin-dependent diabetic patients with macrovascular complications suffer from many geriatric conditions

BACKGROUND

Current diabetic care guidelines focus mainly on managing metabolic control and macro- and microvascular comorbidities. This focus may be too narrow given the number of geriatric conditions present in these often aged patients.

METHODS

We studied the prevalence of multimorbidity, (undiagnosed) geriatric conditions and disabilities in diabetic patients with macrovascular complications.

RESULTS

One hundred forty-three community dwelling, insulin-dependent diabetic patients with macrovascular complications, aged 55 years and above, who were concurrently enrolled in the diabetes care clinic in a university hospital in the Netherlands, participated. Data on healthcare utilization, activities of daily living, geriatric conditions and quality of life were self-reported using a systematic diagnostic questionnaire. Mean age was 66.9 years (8.5 years), 62% were male and 22% were of Surinamese-South Asian descent. Loneliness was reported by 47%. The majority rated their quality of life (QoL) from 'reasonable' (45%) to 'good' (31%). In patients without ADL impairments, 60% were in need of assistance, compared to 95% among those with more than one impairment (p<0.01). In total, 19% had cognitive impairment, and 63% perceived pain. 84% of patients with impairments experienced social problems compared to 32% of patients in the other group.

CONCLUSIONS

This study demonstrates that the current focus of diabetes care may be too restricted given the high number of geriatric conditions that these patients present.

Determinants and costs of community nursing in patients with type 2 diabetes from a community-based observational study: the Fremantle Diabetes Study

BACKGROUND

Despite widespread use, there is little information on the extent and impact of community nursing to patients with type 2 diabetes.

OBJECTIVE

To determine the incidence, predictors and costs of community nursing provision to patients with type 2 diabetes in a large community-based representative study of diabetes in an urban Australian setting.

DESIGN

Prospective observational study utilising data linkage.

SETTING

Postcode defined region in Fremantle, Australia.

PARTICIPANTS

All patients with type 2 diabetes enrolled in the Fremantle Diabetes Study between 1993 and 1996.

METHODS

Eligible patients were followed from July 1997, when home nursing data first became available, to death or census in November 2007. Home nursing data from the major community nursing service provider were linked with data from the Fremantle Diabetes Study. Cox and zero-inflated negative binomial (ZINB) regression modelling was used to identify predictors of incident home visits and visit frequency, respectively. Direct costs were estimated from the service provider's unit costs.

RESULTS

During a mean ± SD 8.6 ± 2.9 years of follow-up, 27.8% of 825 patients (aged 65.2 ± 10.3 years at study entry; 51.2% male) received 21,878 home nursing visits (median frequency 31 [interquartile range 9-85] visits, range 1-1446 visits). In Cox and ZINB models, predictors of home nursing included older age, physical disability measures and macrovascular and microvascular complications. Insulin use was an important predictor of the frequency of visits whilst ethnic and economic factors predicted lower frequency. The estimated cost of home nursing, extrapolated nationally, adds 5% to the total Australian direct health care costs of diabetes.

CONCLUSIONS

Home nursing is frequently utilized in the management of type 2 diabetes with considerable individual variation in the use of this service. Given the associated costs, further research into how home nursing can best be employed is indicated.

Proximity to death is associated with frequency of GP contacts in the oldest old: the Leiden 85-plus study

BACKGROUND

the relationship between proximity to death and the amount of care provided by general practitioners (GPs) is largely unknown.

OBJECTIVE

to examine the influence of the proximity to death on the frequency and length of GP contacts in the oldest old.

STUDY DESIGN

this population-based follow-up study included 599 inhabitants of Leiden, the Netherlands. At ages 85-90 years, the frequency and length of GP contacts during the previous year were collected.

METHODS

the influence of age and proximity to death on contact frequency and time was analysed with linear mixed modelling.

RESULTS

in a model including 'age' alone, mean contact frequency during surviving years increased with 0.25 contacts/year [95% confidence interval (CI) 0.04-0.45, P = 0.019] and mean contact time with 11.04 min/year (95% CI: 5.42-16.67, P < 0.001). In a model including 'age' and 'proximity to death', those who died compared with those who survived had 11.94 contacts (95% CI: 10.86-13.01) more that year and 323 min (95% CI: 294-353, P < 0.001) more time, with no effect of 'age'.

CONCLUSIONS

the observed increase in utilisation of GP care of the oldest old depends more on the proximity to death and less on age alone. Being old only results in a small increase in the GP's workload.

Comorbidity patterns in patients with chronic diseases in general practice

Introduction

Healthcare management is oriented toward single diseases, yet multimorbidity is nevertheless the rule and there is a tendency for certain diseases to occur in clusters. This study sought to identify comorbidity patterns in patients with chronic diseases, by reference to number of comorbidities, age and sex, in a population receiving medical care from 129 general practitioners in Spain, in 2007.

Methods

A cross-sectional study was conducted in a health-area setting of the Madrid Autonomous Region (Comunidad Autónoma), covering a population of 198,670 individuals aged over 14 years. Multiple correspondences were analyzed to identify the clustering patterns of the conditions targeted.

Results

Forty-two percent (95% confidence interval [CI]: 41.8–42.2) of the registered population had at least one chronic condition. In all, 24.5% (95% CI: 24.3–24.6) of the population presented with multimorbidity.

In the correspondence analysis, 98.3% of the total information was accounted for by three dimensions. The following four, age- and sex-related comorbidity patterns were identified: pattern B, showing a high comorbidity rate; pattern C, showing a low comorbidity rate; and two patterns, A and D, showing intermediate comorbidity rates.

Conclusions

Four comorbidity patterns could be identified which grouped diseases as follows: one showing diseases with a high comorbidity burden; one showing diseases with a low comorbidity burden; and two showing diseases with an intermediate comorbidity burden.

Impact of comorbidity and healthcare utilization on colorectal cancer stage at diagnosis: literature review

PURPOSE

Individuals diagnosed with cancer close to death have low access to enrollment in palliative care programs. The purpose of this literature review was to assess the usefulness of pre-diagnostic comorbidity and healthcare utilization as indicators of late-stage colorectal cancer (CRC) diagnosis, to help with early identification of individuals who may benefit from palliative care.

METHODS

A literature search was conducted in relevant databases using title/abstract terms which included "cancer," "stage," "diagnosis," "determinants," "predictors," and "associated." Included studies examined whether comorbidity and/or healthcare utilization had an impact on the stage at which CRC was diagnosed. A standardized data abstraction form was used to assess the eligibility of each study. Thirteen articles were included in the literature review. These studies were assessed and synthesized using qualitative methodology.

RESULTS

We found much heterogeneity among study variables. The findings of this literature review point to the presence of comorbidity and non-emergent healthcare utilization as having no association with late-stage diagnosis. Conversely, emergency room presentation (ERP) was associated with late-stage diagnosis.

CONCLUSIONS

The results of this literature review did not find strong evidence to suggest that comorbidity and healthcare utilization are potential indicators of late-stage diagnosis. However, ERP may be useful as a flag for consideration of prompt referral to palliative care. Additional research is required to identify potential indicators of late-stage diagnosis that may be available in administrative databases, particularly in the area of healthcare utilization.

Co-occurrence of diabetes, myocardial infarction, stroke, and cancer: quantifying age patterns in the Dutch population using health survey data

Background

The high prevalence of chronic diseases in Western countries implies that the presence of multiple chronic diseases within one person is common. Especially at older ages, when the likelihood of having a chronic disease increases, the co-occurrence of distinct diseases will be encountered more frequently. The aim of this study was to estimate the age-specific prevalence of multimorbidity in the general population. In particular, we investigate to what extent specific pairs of diseases cluster within people and how this deviates from what is to be expected under the assumption of the independent occurrence of diseases (i.e., sheer coincidence).

Methods

We used data from a Dutch health survey to estimate the prevalence of pairs of chronic diseases specified by age. Diseases we focused on were diabetes, myocardial infarction, stroke, and cancer. Multinomial P-splines were fitted to the data to model the relation between age and disease status (single versus two diseases). To assess to what extent co-occurrence cannot be explained by independent occurrence, we estimated observed/expected co-occurrence ratios using predictions of the fitted regression models.

Results

Prevalence increased with age for all disease pairs. For all disease pairs, prevalence at most ages was much higher than is to be expected on the basis of coincidence. Observed/expected ratios of disease combinations decreased with age.

Conclusion

Common chronic diseases co-occur in one individual more frequently than is due to chance. In monitoring the occurrence of diseases among the population at large, such multimorbidity is insufficiently taken into account.

Longitudinal administrative data can be used to examine multimorbidity, provided false discoveries are controlled for

OBJECTIVE

This article presents methods for using administrative data to study multimorbidity in hospitalized individuals and indicates how the findings can be used to gain a deeper understanding of hospital multimorbidity.

STUDY DESIGN AND SETTING

A Dutch nationwide hospital register (n=4,521,856) was used to calculate age- and sex-standardized observed/expected ratios of disease-pairing prevalences with corresponding confidence intervals.

RESULTS

The strongest association was found for the combination between alcoholic liver and mental disorders due to alcohol abuse (observed/expected=39.2). Septicemia was found to cluster most frequently with other diseases. The consistency of the ratios over time depended on the number of observed cases. Furthermore, the ratios also depend on the length of the time frame considered.

CONCLUSION

Using observed/expected ratios calculated from the administrative data set, we were able to (1) better quantify known morbidity pairings while also revealing hitherto unnoticed associations, (2) find out which pairings cluster most strongly, and (3) gain insight into which diseases cluster frequently with other diseases. Caveats with this method are finding spurious associations on the basis of too few observed cases and the dependency of the ratio magnitude on the length of the time frame observed.

Utilization of acute and long-term care in the last year of life: comparison with survivors in a population-based study

BACKGROUND

It is well-known that the use of care services is most intensive in the last phase of life. However, so far only a few determinants of end-of-life care utilization are known. The aims of this study were to describe the utilization of acute and long-term care among older adults in their last year of life as compared to those not in their last year of life, and to examine which of a broad range of determinants can account for observed differences in care utilization.

METHODS

Data were used from the Longitudinal Aging Study Amsterdam (LASA). In a random, age and sex stratified population-based cohort of 3107 persons aged 55 - 85 years at baseline and representative of the Netherlands, follow-up cycles took place at 3, 6 and 9 years. Those who died within one year directly after a cycle were defined as the "end-of-life group" (n = 262), and those who survived at least three years after a cycle were defined as the "survivors". Utilization of acute and long-term care services, including professional and informal care, were recorded at each cycle, as well as a broad range of health-related and psychosocial variables.

RESULTS

The end-of-life group used more care than the survivors. In the younger-old this difference was most pronounced for acute care, and in the older-old, for long-term care. Use of both acute and long-term home care in the last year of life was fully accounted for by health problems. Use of institutional care at the end of life was partly accounted for by health problems, but was not fully explained by the determinants included.

CONCLUSION

This study shows that severity of health problems are decisive in the explanation of the increase in use of care services towards the end-of-life. This information is essential for an appropriate allocation of professional health care to the benefit of older persons themselves and their informal caregivers.

The relationship between effectiveness and costs measured by a risk-adjusted case-mix system: multicentre study of Catalonian population data bases

Background

The main objective of this study is to measure the relationship between morbidity, direct health care costs and the degree of clinical effectiveness (resolution) of health centres and health professionals by the retrospective application of Adjusted Clinical Groups in a Spanish population setting. The secondary objectives are to determine the factors determining inadequate correlations and the opinion of health professionals on these instruments.

Methods/Design

We will carry out a multi-centre, retrospective study using patient records from 15 primary health care centres and population data bases. The main measurements will be: general variables (age and sex, centre, service [family medicine, paediatrics], and medical unit), dependent variables (mean number of visits, episodes and direct costs), co-morbidity (Johns Hopkins University Adjusted Clinical Groups Case-Mix System) and effectiveness.

The totality of centres/patients will be considered as the standard for comparison. The efficiency index for visits, tests (laboratory, radiology, others), referrals, pharmaceutical prescriptions and total will be calculated as the ratio: observed variables/variables expected by indirect standardization.

The model of cost/patient/year will differentiate fixed/semi-fixed (visits) costs of the variables for each patient attended/year (N = 350,000 inhabitants). The mean relative weights of the cost of care will be obtained. The effectiveness will be measured using a set of 50 indicators of process, efficiency and/or health results, and an adjusted synthetic index will be constructed (method: percentile 50).

The correlation between the efficiency (relative-weights) and synthetic (by centre and physician) indices will be established using the coefficient of determination. The opinion/degree of acceptance of physicians (N = 1,000) will be measured using a structured questionnaire including various dimensions. Statistical analysis: multiple regression analysis (procedure: enter), ANCOVA (method: Bonferroni's adjustment) and multilevel analysis will be carried out to correct models. The level of statistical significance will be p < 0.05.

Public and private healthcare services utilization by non-institutional elderly in Hong Kong: is the inverse care law operating?

OBJECTIVES

To assess the factors associated with healthcare services utilization by the non-institutional elderly across five types of service utilization (Western medicine doctors in Government clinics, private Western medicine doctors, Chinese medicine practitioners, Emergency Units, and hospitalization).

METHODS

A secondary data analysis of a territory-wide cross-sectional survey collected by the Government among a representative sample of 4812 elderly (aged 60 and above) in Hong Kong.

RESULTS

Our analysis, based on Anderson's behavioral framework, shows that need factors (relating to actual or perceived illness and diseases) are significantly related to the healthcare services utilization examined. However, enabling factors, such as monthly household income per capita, play a significant role in determining the utilization. Although the lower-income elderly consult more Government clinics and less private clinics than the more affluent, they have a lower total utilization of healthcare services despite having significantly greater healthcare needs.

CONCLUSIONS

This suggests a mismatch of need and supply within the mixed economy of private and public healthcare services and suggests the existence of an 'inverse care law' in Hong Kong amongst elderly citizens. The findings raise concerns of inequities in Hong Kong's healthcare system, raising implications for future healthcare reforms.

Investigating the longer-term health consequences of work-related injuries among youth

PURPOSE

To investigate the longer-term health consequences of work injuries among youth aged 15-24 years using a population-based, longitudinal study (1991-2001) of merged health care and workers' compensation records.

METHODS

A group-based modeling approach was used (1) to identify unique trajectories of health care use defined by general practitioner visits among the study sample stratified by gender, and (2) to determine the injury factors that predict a youth's membership in a trajectory, adjusted for sociodemographic factors.

RESULTS

Four long-term trajectories of health care use were identified among young injured workers, for both males and females. Similar trajectories were observed among a comparison, noninjured sample but the magnitude of health care use was consistently higher among the injured worker cohort, especially for females (attributable to general practitioner [GP] visits for symptoms, signs and ill-defined diagnoses), and a notable "spike" in health care use occurred in the year immediately after a work injury for both males and females that was not observed in the comparison population during the matched year (attributable to GP visits for musculoskeletal and injury diagnoses). For males, the type of work injury mattered with an increased odds of belonging to the higher health care trajectories associated with a musculoskeletal injury (odds ratio [OR] = 1.57, 95% CI = .76, 3.23; and OR = 1.61, 95% CI 1.08, 2.41 for the postinjury trajectories), adjusted for age, occupation, socioeconomic status, and geographic location.

CONCLUSION

Persistent use of health care services may represent a cumulative burden of morbidity over the life course as a result of a work-related injury in general among young women and as a result of musculoskeletal injuries in particular among males.

[Patients with multimorbidity in the hospital setting]

OBJECTIVES

Hospitals attend patients with multiple chronic diseases. The aim of the present study was to estimate the prevalence of these patients, as well as their main sociodemographic and management characteristics.

METHODS

We performed a descriptive study based on information from the minimum data set and a functional definition of patients with multimorbidity. Age, sex, admitting specialty, cause of admission, discharge and days of hospital stay were estimated for patients discharged from a university hospital in 2003.

RESULTS

Patients with multimorbidity represented 16.9% (95% CI: 15.8-18.1%) of admissions. These patients were mainly elderly men who tended to be admitted urgently to medical specialties. Discharge to home was less frequent and days of hospital stay tended to be longer.

CONCLUSIONS

Patients with multiple comorbidities have well-defined characteristics that allow them to be retrospectively identified through analysis of the minimum data set. Although nearly all services discharged these patients, most of them were discharged from medical specialties.