Observed and expected frequency of comorbid chronic diseases in rheumatic patients

Clustering of comorbidities

Within the last decade, clustering of comorbidities has become an increasing health problem on a global scale and will continue to challenge healthcare professionals in the coming years. People with multiple diseases find difficulties in managing their daily lives due to the implications each disease brings; attending and keeping up to date with hospital appointments, being prescribed and taking various medications, the effects of mental health and quality of life, and the impact it has on their families. Most research in clinical trials often exclude individuals with multimorbidity and observational studies mainly focus on single disease outcomes, therefore there is an opportunity to encourage future research in an area which could help prevent further cases and improve the lives of those already living with multimorbidity. This review aims to summarise the rising prevalence and most common clusters, highlight the challenges faced in healthcare, and explore ways to improve future research.

Prevalence and impact of non-cardiovascular comorbidities among older adults hospitalized for non-ST segment elevation acute coronary syndrome

Background

There is a paucity of information on the prognostic importance of non-cardiovascular comorbidities (NCCs) among patients with non-ST-elevation acute coronary syndrome (NSTE-ACS). This study examined the prevalence and impact of NCCs on the length of stay (LOS) and mortality among older adults hospitalized for NSTE-ACS.

Methods

Among 1,488 older adults (mean age 79.4±8.4 years; 62.0% male) hospitalized for NSTE-ACS at a tertiary hospital in Melbourne, Australia, during 2013-2015, we collected data on comorbidities, LOS, and discharge outcomes. Thirteen NCCs were studied. Negative binomial and Cox proportional regression models were applied to examine the association between NCCs and LOS and in-hospital death, respectively.

Results

Approximately 53% of the patients had ≥1 NCCs. Diabetes and renal disease as well as anemia and renal disease co-existed more frequently than expected. Compared to having no NCCs, having one NCC was not associated with a significant increase in the likelihood of longer LOS [incidence rate ratio (IRR) 1.07; 95% CI: 0.99-1.15; P=0.085] or in-hospital death [hazard ratio (HR) 1.11; 95% CI: 0.65-1.90; P=0.707]. However, having ≥2 NCCs was associated with 22% and 79% increased likelihood of longer LOS (IRR 1.22, 95% CI: 1.11-1.33; P<0.001) and in-hospital death (HR 1.79, 95% CI: 1.06-3.03; P=0.029), respectively, compared to not having any NCC. Certain NCC dyads [e.g., chronic pulmonary disease (CPD) + renal disease] exhibited multiplicative effect such that their impact on patients' LOS or survival exceeded the sum of the individual effects of the component NCCs.

Conclusions

Over half of older patients hospitalized with NSTE-ACS had NCCs. A higher burden of NCCs correlated with increased LOS and lower survival. Contemporary ACS management guidelines need to recognize and incorporate protocols for the treatment of individuals with multiple chronic conditions to reduce the occurrence of adverse outcomes.

Pain assessment in Spanish rheumatology outpatient clinics: EVADOR Study

INTRODUCTION

rheumatic diseases are the most frequent cause of non-malignant chronic pain. In recent years, pain and its management have become more important in rheumatology.

OBJECTIVES

to estimate the prevalence and characteristics of pain associated with rheumatic pathology treated in rheumatology clinics in Spain, as well as their treatment and response to it.

METHODS

Multicentre observational study with two phases (cross-sectional and prospective). Variables were collected from the doctor, patient, pain and its management, comorbidities, therapeutic response and related psychosocial aspects. The differences between de novo (NP) vs follow-up (FP) patients were analyzed.

RESULTS

34 centres and 1084 patients were included, 32% NP and 68% FP. Pain was present in 86%, was chronic in 81% and neuropathic in 12% of the surveyed population. Fifty percent of the patients would regard their pain as tolerable if its intensity according to the visual numeric scale (VNS) was≤2. Among the FP it was more frequent to have the perception of controlled pain (65.5% vs 49.4%) and to be satisfied with the treatment (53.3% vs. 35.6%). Of these patients, 23.5% had been treated with opioids in the previous month.

CONCLUSIONS

In the last decade, the prevalence of pain in rheumatology in Spain remains high, although it has diminished. The use of opioids, on the other hand, has increased.

The impact of different rheumatic diseases on health-related quality of life: a comparison with a selected sample of healthy individuals using SF-36 questionnaire, EQ-5D and SF-6D utility values

BACKGROUND

Given the high prevalence of rheumatic diseases, there is a need to determine which conditions have the greatest impact on health-related quality of life (HRQoL). The main aim of this study was to explore the HRQoL scores among 14 different rheumatic diseases and to compare them with the results of a selecting sample of healthy controls.

METHODS

2633 patients of an ongoing cohort have been enrolled. Rheumatic diseases were classified into five diagnostic groups: inflammatory rheumatic diseases, connective tissue disorders, symptomatic peripheral osteoarthritis, soft tissue disorders, and osteoporosis. For comparison were used 649 healthy controls. The HRQoL was evaluated with the Medical Outcomes Study Short-Form 36 Health Survey (SF-36), the EuroQol five Dimensions (EQ-5D) questionnaire, and the Short-Form six Dimensions (SF-6D) questionnaire.

RESULTS

The five major rheumatic disease groups, compared to healthy people, significantly impaired all eight health concepts of the SF-36 (p <0.0001). Similar results were found for EQ-5D and SF-6D. The patients with inflammatory rheumatic diseases have poorer self-reported health status than those without arthritis in all domains of living, but particularly with respect to scales measuring aspects of physical functioning or mobility, role limitation due to physical health problems and usual activities, and bodily pain. Rheumatoid arthritis had the largest negative impact on HRQoL, followed by fibromyalgia, vertebral fractures due to osteoporosis, hip osteoarthritis, and systemic sclerosis.

CONCLUSIONS

Our results indicate that rheumatic diseases have a clearly detrimental effect on the HRQoL, and physical domain is more impaired than mental and social ones.

Patterns of Medication Dispensation for Multiple Comorbidities among Older Adults in Australia

Background: The increasing burden of chronic (medical) conditions (CCs) is a major issue for healthcare systems across the world. We aimed to examine the changes in the rate of medication dispensation for multiple CCs among Australians aged ≥65 years. Methods: A repeated cross-sectional study was performed using the 2013⁻2016 Pharmaceutical Benefits Scheme (PBS) data on reimbursed prescriptions for a 10% random sample of the Australian population. Twenty-two CCs were identified via the RxRisk-V tool. The yearly changes in the proportion of older adults dispensed medications for ≥2 CCs were determined through Poisson regression modelling using 2013 as the reference year. The occurrence of CC dyads and triads for which medications were dispensed within a 180-day window were characterised, and the observed and expected rate of medication dispensation for each CC dyad or triad were calculated to identify the top 15 combinations. Results: The proportion of older adults dispensed medications for ≥2 CCs remained stable from 2013 to 2016, at >79% in each year. The proportion who were dispensed medications for multiple CCs increased with age. No gender differences in the dispensation of medications for multiple CCs were observed. Over 60% had medications dispensed for ≥3 CCs. The most frequent CC dyad and triad for which medications were dispensed were dyslipidaemia + hypertension (38.6%) and dyslipidaemia + gastroesophageal reflux disease + hypertension (18.7%), respectively. For the majority of CC dyads and all triads examined, the observed rate of medication dispensation exceeded that expected by chance. Conclusions: A high proportion of older Australians are dispensed medications for multiple CCs, suggestive of multimorbidity. The results reiterate the need for increased research into understanding the causal mechanisms of multimorbidity to inform the design of cost-effective interventions.

Associations between multimorbidity and additional burden for working-age adults with specific forms of musculoskeletal conditions: a cross-sectional study

BACKGROUND

Multiple health conditions are increasingly a problem for adults with musculoskeletal conditions. However, multimorbidity research has focused primarily on the elderly and those with a limited subset of musculoskeletal disorders. We sought to determine whether associations between multimorbidity and additional burden differ with specific forms of musculoskeletal conditions among working-age adults.

METHODS

Data were sourced from a nationally representative Australian survey. Specific musculoskeletal conditions examined were osteoarthritis; inflammatory arthritis; other forms of arthritis or arthropathies; musculoskeletal conditions not elsewhere specified; gout; back pain; soft tissue disorders; or osteoporosis. Multimorbidity was defined as the additional presence of one or more of the Australian National Health Priority Area conditions. Burden was assessed by self-reported measures of: (i) self-rated health (ii) musculoskeletal-related healthcare and medicines utilisation and, (iii) general healthcare utilisation. Associations between multimorbidity and additional health or healthcare utilisation burden among working-age adults (aged 18 - 64 years of age) with specific musculoskeletal conditions were estimated using logistic regression, adjusting for confounders. Interaction terms were fitted to identify whether there were specific musculoskeletal conditions where multimorbidity was more strongly associated with poorer health or greater healthcare utilisation than in the remaining musculoskeletal group.

RESULTS

Among working-age adults, for each of the specified musculoskeletal conditions, multimorbidity was associated with similar, increased likelihood of additional self-rated health burden and certain types of healthcare utilisation. While there were differences in the relationships between multimorbidity and burden for each of the specific musculoskeletal conditions, no one specific musculoskeletal condition appeared to be consistently associated with greater additional health burden in the presence of multimorbidity across the majority of self-rated health burden and healthcare use measures.

CONCLUSIONS

For working-age people with any musculoskeletal conditions examined here, multimorbidity increases self-reported health and healthcare utilisation burden. As no one musculoskeletal condition appears consistently worse off in the presence of multimorbidity, there is a need to better understand and identify strategies that acknowledge and address the additional burden of concomitant conditions for working-age adults with a range of musculoskeletal conditions.

Cross-sectional examination of musculoskeletal conditions and multimorbidity: influence of different thresholds and definitions on prevalence and association estimates

BACKGROUND

Multimorbidity and musculoskeletal conditions create substantial burden for people and health systems. Quantifying the extent of co-occurring conditions is hampered by conceptual heterogeneity, imprecision and/or indecision about how multimorbidity is defined. The purpose of this study is to examine the influence of different ways of operationalising multimorbidity on multimorbidity prevalence rates with a focus on working-age adults with musculoskeletal conditions. Weighted population prevalence rates of multimorbidity among working-age Australians were estimated using data from the National Health Survey. Two nominal thresholds (2+ or 3+ co-occurring conditions) and three operational definitions of multimorbidity (survey-, policy- and research-based) were examined. Using logistic regression, we estimated the association between the prevalence of multimorbidity among persons with musculoskeletal conditions compared to persons with non-musculoskeletal conditions for each definition and threshold combination.

RESULTS

As few as 7.9% of working-age Australians have 2+ conditions using the research-based definition (95% CI 7.4-8.5%), compared to estimates of 15.3% (95% CI 14.3-16.2%) and 61.5% (95% CI 60.3-62.7%). with the policy- and survey-based definitions, respectively. Depending on definition, with the 3+ threshold multimorbidity prevalence ranged from 2.1% (research) to 41.9% (survey). Among the sub-sample with musculoskeletal conditions, multimorbidity with the 2+ threshold ranged from 20.2 to 92.2%; and with 3+ threshold from 5.9 to 75.4%, again lowest with the research-definition and highest with the survey-definition. When compared to any other condition (i.e. non-musculoskeletal conditions), all musculoskeletal conditions were positively associated with multimorbidity, regardless of definition or threshold.

CONCLUSIONS

Depending on definition and threshold, multimorbidity is either rare or endemic in working-age Australians. Irrespective of definition, musculoskeletal conditions are a near-ubiquitous feature of multimorbidity.

Fibromyalgia is associated to receiving chronic medications beyond appropriateness: a cross-sectional study

The objectives of this study are to describe appropriateness and drug treatment of comorbidities in fibromyalgia (FM). Cross-sectional study of a group of patients. Number of drugs, indication, duration and appropriateness of prescriptions were evaluated. Patients were classified as: group 1, (FM/FM) previous FM diagnosis and fulfilling criteria; group 2, (noFM/noFM) other diagnosis and not fulfilling criteria; and group 3, (noFM/FM) other diagnosis but fulfilling criteria. Drugs were classified into drugs for nervous system, analgesics/NSAID and drugs for other comorbidities. Appropriateness was evaluated following clinical therapeutic guidelines. A total of 159 patients were included in the study and classified into group 1, with 59 patients; group 2, with 67 patients; and group 3, with 33 patients. Group 1 received a greater number of different drugs and for a longer period of time, there were less severe comorbidities and more unjustified treatments. No difference was found between the other two groups. Major opioids were only consumed in group 1. Also, in group 1, 45.8 % of patients were attended in psychiatry versus 15.6 % in group 3 and 3 % in group 2. The number of somatic symptoms correlated significantly with the number of drugs. Nervous system treatments were of shorter duration than other drug treatments. There was no difference in severe comorbidities. Comorbidities in FM are similar to those of other patients, but they receive more drugs and for a longer period of time. Drugs for nervous system comorbidities are introduced later, when other somatic symptoms are already treated. In patients with FM the treatments for mild comorbidities are not well justified.

Fifteen-year trend in information on the World Wide Web for patients with rheumatoid arthritis: evolving, but opportunities for improvement remain

The aim of this study was to assess the changes in the characteristics of rheumatoid arthritis information on the Internet over a 15-year period and the positioning of Web sites posted by universities, hospitals, and medical associations. We replicated the methods of a 2001 study assessing rheumatoid arthritis information on the Internet using WebCrawler. All Web sites and pages were critically assessed for relevance, scope, authorship, type of publication, and financial objectives. Differences between studies were considered significant if 95 % confidence intervals did not overlap. Additionally, we added a Google search with assessments of the quality of content of web pages and of the Web sites posted by medical institutions. There were significant differences between the present study's WebCrawler search and the 2001-referent study. There were increases in information sites (82 vs 36 %) and rheumatoid arthritis-specific discussion pages (59 vs 8 %), and decreases in advertisements (2 vs 48 %) and alternative therapies (27 vs 45 %). The quality of content of web pages is still dispersed; just 37 % were rated as good. Among the first 300 hits, 30 (10 %) were posted by medical institutions, 17 of them in the USA. Regarding readability, 7 % of these 30 web pages required 6 years, 27 % required 7-9 years, 27 % required 10-12 years, and 40 % required 12 or more years of schooling. The Internet has evolved in the last 15 years. Medical institutions are also better positioned. However, there are still areas for improvement, such as the quality of the content, leadership of medical institutions, and readability of information.

Readability, relevance and quality of the information in Spanish on the Web for patients with rheumatoid arthritis

BACKGROUND

Education is a major health determinant and one of the main independent outcome predictors in rheumatoid arthritis (RA). The use of the Internet by patients has grown exponentially in the last decade.

OBJECTIVE

To assess the characteristics, legibility and quality of the information available in Spanish in the Internet regarding to rheumatoid arthritis.

MATERIAL AND METHODS

The search was performed in Google using the phrase rheumatoid arthritis. Information from the first 30 pages was evaluated according to a pre-established format (relevance, scope, authorship, type of publication and financial objective). The quality and legibility of the pages were assessed using two validated tools, DISCERN and INFLESZ respectively. Data extraction was performed by senior medical students and evaluation was achieved by consensus.

RESULTS

The Google search returned 323 hits but only 63% were considered relevant; 80% of them were information sites (71% discussed exclusively RA, 44% conventional treatment and 12% alternative therapies) and 12.5% had a primary financial interest. 60% of the sites were created by nonprofit organizations and 15% by medical associations. Web sites posted by medical institutions from the United States of America were better positioned in Spanish (Arthritis Foundation 4th position and American College of Rheumatology 10th position) than web sites posted by Spanish speaking countries.

CONCLUSIONS

There is a risk of disinformation for patients with RA that use the Internet. We identified a window of opportunity for rheumatology medical institutions from Spanish-speaking countries to have a more prominent societal involvement in the education of their patients with RA.

Changing definitions altered multimorbidity prevalence, but not burden associations, in a musculoskeletal population

OBJECTIVES

The inclusion of musculoskeletal conditions within multimorbidity research is inconsistent, and working-age populations are largely ignored. We aimed to: (1) estimate multimorbidity prevalence among working-age individuals with a range of musculoskeletal conditions; and (2) better understand the implications of decisions about the number and range of conditions constituting multimorbidity on the strength of associations between multimorbidity and burden (e.g., health status and health care utilization).

STUDY DESIGN AND SETTING

Using data from the Australian National Health Survey 2007-08, the associations between burden measures and three ways of operationalizing multimorbidity (survey, policy, and research based) within the working-age (18-64 years) musculoskeletal population were estimated using multiple logistic regression (age and gender adjusted).

RESULTS

Depending on definition, from 20.2% to 75.4% of working-age individuals with musculoskeletal conditions have multimorbidity. Irrespective of definition, multimorbidity was associated with increased likelihood of subjective health burden, pain or musculoskeletal medicines use, nonmusculoskeletal specialist and pharmacist (advice only) consultations, and reduced likelihood of not consulting health professionals. A group with intermediate health outcomes was considered multimorbid by some, but not all definitions. With the restrictive policy and research multimorbidity definitions, this intermediate group is included within the reference population (i.e., are considered nonmultimorbid). This worsens the reference group's apparent health status thereby leveling the comparative burden between those with and without multimorbidity. Consequently, dichotomous cut points lead to similar associations with burden measures despite the increasingly restrictive multimorbidity definitions used.

CONCLUSIONS

All multimorbidity definitions were associated with burden among the working-age musculoskeletal population. However, dichotomous cut points obscure the gradient of increased burden associated with restrictive definitions.

Autoantibodies in prediction of the development of rheumatoid arthritis among healthy relatives of patients with the disease

OBJECTIVE

Although blood bank-based studies have shown that rheumatoid arthritis (RA)-related autoantibodies are present before the onset of RA, information on their positive predictive value (PPV) for development of RA in healthy individuals is scarce. This study was undertaken to assess the 5-year PPV of serum IgM rheumatoid factor (IgM-RF) and anti-cyclic citrullinated peptide (anti-CCP) for the development of RA among healthy relatives of patients with RA.

METHODS

Healthy relatives of RA patients were invited to participate in a cohort study. At baseline, information on participants' medical history was obtained, and serum levels of IgM-RF and anti-CCP antibodies were determined (by nephelometry and second-generation anti-CCP enzyme-linked immunosorbent assay, respectively). The subjects were followed up every 4 months via a structured interview (Community Oriented Program for Control of Rheumatic Diseases [COPCORD] questionnaire). When the COPCORD questionnaire indicated possible arthritis, subjects underwent an in-office rheumatology assessment including joint count. The study end point was defined as fulfillment of the American College of Rheumatology criteria for RA.

RESULTS

Eight hundred nineteen initially healthy relatives of 252 patients with RA were included (69% female, 41% offspring, mean ± SD age 35 ± 12 years). Eleven (1.3%) were positive for both anti-CCP-2 and RF, 12 (1.5%) only for anti-CCP-2, and 16 (2%) only for RF. RA developed in 17 (2.1%) of the relatives during the 5-year followup (3,313 person-years for the seronegative group and 60.8 person-years for the anti-CCP-2-positive group). The PPV was 64% when both anti-CCP-2 and RF were positive and 58% when only anti-CCP-2 was positive. Offspring of patients with RA had an independent 3-fold increased risk of developing RA.

CONCLUSION

Results of the present study indicate that the magnitude of risk for developing RA in healthy relatives of patients with RA can be estimated using simple routine laboratory tests.

Increased occurrence of cardiovascular events and comorbidities in a general rheumatology cohort

BACKGROUND

To identify cardiovascular and other comorbidities in a general rheumatology cohort.

METHODS

Interviews/retrospective chart audits were conducted on 1,000 patients attending rheumatology outpatient clinics of a university teaching hospital. Comorbidities were classified using the Charlson comorbidity index (Ambrose et al. in Ir J Med Sci 178(1):53-55, 2009).

RESULTS

Mean age 58 +/- 15.3 years, mean BMI 26. Of the patients, 400 (40%) were diagnosed with dyslipidemia and hypertension (p = 0.002), 160 (16%) with obesity and 80 (8%) with hypothyroidism. Overall 160 (16%) patients were diagnosed with coronary heart disease (CHD). Of these, 120 (75%) had RA (p = 0.001), 100 (63%) were male, mean age 60 +/- 15.8 years, 120 (75%) had dyslipidemia and BMI > 30 (p = 0.002), 112 (70%) were smokers (p = 0.002), 40 (25%) were diagnosed with diabetes mellitus and 20 (12%) with hypothyroidism.

CONCLUSIONS

The increased prevalence of these comorbidities may serve as a reminder to the rheumatologists that many of their patients will have coexistent disease of which they need to be aware to properly plan their management.

Multimorbidity: prevalence, effect on quality of life and daily functioning, and variation of this effect when one condition is a rheumatic disease

OBJECTIVES

To examine the prevalence and effect of multimorbidity on health-related quality of life (HRQoL) and daily functioning in the general population, and to analyze the influence on HRQoL and daily functioning of multimorbidity including a rheumatic disease.

METHODS

A national health survey was conducted on 2192 randomly selected adults in Spain. Multimorbidity was defined as the co-occurrence of at least 2 chronic diseases, as defined by self-report. All subjects completed the 12-item short form (SF-12) health survey and the Health Assessment Questionnaire (HAQ). Estimates and 95% confidence intervals (CI) of the prevalence of multimorbidity were obtained. The effect on HAQ and SF-12 scores is presented as beta-coefficients obtained from multiple linear regressions.

RESULTS

The estimated prevalence of multimorbidity was 30% (95% CI 25 to 34), and the prevalence of multimorbidity including a rheumatic disease was 17% (95% CI 13 to 20). Multimorbidity was associated with impaired daily functioning [HAQ beta = 0.07 (95% CI 0.02 to 0.11)], and lower HRQoL [SF-12(physical component) beta = -4.2 (95% CI -5.2 to -3.22); SF-12(mental dimension) beta = -3.3 (95% CI -4.5 to -2.2)]. Subjects with multimorbidity including a rheumatic disease reported worse scores than those without a rheumatic disease: HAQ beta 0.13 (95% CI 0.07 to 0.18) versus -0.03 (95% CI -0.08 to 0.02), and SF-12(physical component) beta -6.5 (95% CI -5.2 to -3.2) versus 0.5 (95% CI -0.7 to 1.7).

CONCLUSIONS

Multimorbidity is frequent in the general population and can considerably impair daily functioning and HRQoL. Having a rheumatic disease worsens these outcomes.