Household and area-level social determinants of multimorbidity: a systematic review

The dialogue dilemma: the role of patient-clinician communication for low-income people who smoke and manage multiple conditions

Introduction

Adults from low-income backgrounds who smoke face significant health disparities related to tobacco use, often at disproportionately high rates. These individuals are more likely to endure multiple mental and physical (MP) health conditions, which can negatively influence their self-rated health (SRH). The quality and effectiveness of patient-clinician communication (PCC) can influence how patients perceive their own health. Understanding how PCC influences SRH among low-income adults who smoke and suffer from multiple MP conditions is essential for clinical care as multimorbidity is on the rise. This study examines how PCC may influence the health perceptions of low-income adults who smoke and have varying MP conditions.

Methods

Low-income adults who smoke (N = 58) were recruited from the San Francisco Health Network (SFHN) and were assessed for number of MP conditions, PCC, and SRH. A moderation analysis was performed to examine whether PCC moderated relations between MP conditions and SRH. Follow-up analyses were conducted to examine differences and relationships among variables. In planned exploratory analysis, all possible choices for moderator-independent-dependent-variable selections to explore the best model fit were conducted.

Results

The results revealed that PCC moderated the association between MP conditions (p < 0.05) and SRH. In follow-up analyses, number of MP conditions predicted poorer SRH for low-income smokers who experienced low (p < 0.001) and average (p < 0.01) levels of PPC but not high levels of PCC. In planned exploratory analysis, based on the Akaike Information Criterion, a quantitative basis for considering SRH as the dependent variable was established.

Conclusion

The intersection of tobacco-related disparities among low-income adults who smoke and manage multiple MP conditions is complex. Among this vulnerable population, poor and average PCC adversely influences how patients perceive their own health. Results highlight the importance of quality and effective communication between patients and providers. A culturally informed patient-centered approach to care may improve PCC as it encourages collaborative, individually tailored treatment that empowers patients to actively participate in their own health care.

Nurse Practitioner Care Environments and Provider Shortages Among Patients With Multiple Chronic Conditions

In health professional shortage areas (HPSAs), primary care providers face challenges due to high workloads and limited resources, impacting their ability to provide comprehensive care to patients with multiple chronic conditions (MCCs). In addition, patients in HPSA compared to non-HPSA settings experience poorer outcomes. Nurse practitioners (NPs) play a crucial role in meeting MCC patients' needs, but some work in unfavorable care environments (e.g., lacking teamwork, support, and autonomy) that hinder their capacity to manage complex chronic diseases. This study examines the effect of NP care environments on the relationship between HPSA status and hospitalizations or emergency department (ED) visits among patients with MCCs. We conducted a secondary analysis of merged Medicare claims, NP survey data, and Health Resources and Services Administration data. Our sample included 779 practices with 394,424 Medicare beneficiaries aged 65+ who had at least two of 15 chronic conditions. We used logistic regression to evaluate the impact of HPSA status and the NP care environment on ED visits or hospitalizations. NP care environments moderate the association between HPSA status and hospitalization (AOR 1.165, 95% CI [1.037-1.309], p = 0.010) but not ED use. Improved care environments are associated with lower odds of hospitalization in non-HPSAs (β = -0.148, 95% CI [-0.225, -0.072], p = 0.0001), while in HPSAs, improved care environments have no effect on hospitalization odds (β = 0.0047, 95% CI [-0.086, 0.096], p = 0.920). Addressing provider shortages in HPSAs may allow an improved NP care environment to produce maximal benefits for patients.

Impact of Multimorbidity on Symptom Burden and Symptom Clusters in Patients Receiving Chemotherapy

BACKGROUND

Detailed information on patient characteristics and symptom burden associated with multimorbidity in oncology patients is extremely limited. Purposes were to determine the prevalence of low (≤ 2) and high (≥ 3) multimorbidity in a sample of oncology outpatients (n = 1343) undergoing chemotherapy and evaluate for differences between the two multimorbidity groups in demographic and clinical characteristics; the occurrence, severity, and distress of 38 symptoms; and the stability and consistency of symptom clusters.

METHODS

Using the Self-Administered Comorbidity Questionnaire, patients were classified into low and high multimorbidity groups. Memorial Symptom Assessment Scale was used to assess the occurrence, severity, and distress of 38 symptoms prior to the patients' second or third cycle of chemotherapy. For each multimorbidity group, symptom clusters based on occurrence rates were identified using exploratory factor analysis.

RESULTS

Compared to the low group (61.4%), patients in the high group (38.6%) were older, had fewer years of education, were less likely to be married or partnered, less likely to be employed, and had a lower annual income. In addition, they had a higher body mass index, poorer functional status, were a longer time since their cancer diagnosis, and were more likely to have received previous cancer treatments and have metastatic disease. Patients in the low and high groups reported 12.7 (±6.7) and 15.9 (±7.5) concurrent symptoms, respectively. Eight and seven symptom clusters were identified for the low and high groups, respectively. Psychological, gastrointestinal, weight gain, hormonal, and respiratory clusters were stable across multimorbidity groups. Weight gain and respiratory clusters were consistent. Three unstable clusters were identified in the low group and two in the high group.

CONCLUSIONS

Findings suggest that higher multimorbidity is associated with various social determinants of health and a higher symptom burden. Differences between multimorbidity groups may be related to aging, treatments, and/or comorbid conditions.

Associations of built environment features with multimorbidity: A systematic review protocol

Introduction

Preventing or delaying multimorbidity (people living with two or more chronic conditions) is a public health priority. It is currently uncertain if multimorbidity is associated with features of the built environment, a term describing human-made or modified features of the surroundings in which humans live.

Aims

To undertake a systematic review of the literature to determine if built environment features and interventions are associated with multimorbidity and to review the analytical methods used and their implications for causal inference.

Methods

Four databases will be searched (Medline, Embase, Science Citation Index Expanded, and Social Sciences Citation Index) using a prespecified search strategy that incorporates terms for both multimorbidity and the built environment, which includes aspects of neighbourhood design, transport interventions, natural environment, food environments, and housing. Inclusion criteria will include: 1) involves community-based adult populations not selected based on an index condition; and 2) a built environment exposure or intervention was assessed; and 3) outcomes include multimorbidity prevalence, incidence, or trajectory. Reference lists of included studies and previous reviews will also be searched. Two reviewers will independently screen, data extract, and quality appraise (using the ROBINS-E or RoB 2 tool). Results will be synthesised by meta-analysis or, if heterogeneity is too great, according to Synthesis without meta-analysis (SWiM) guidelines. Results will be grouped by type of exposure or intervention and by study quality.

Conclusions

This systematic review will improve understanding of built environment associations with multimorbidity. It could identify aetiological pathways that support the development of multimorbidity-preventative strategies.

Building ADMISSION - A research collaborative to transform understanding of multiple long-term conditions for people admitted to hospital

Background

Multiple long-term conditions (MLTCs; commonly referred to as multimorbidity) are highly prevalent among people admitted to hospital and are therefore of critical importance to hospital-based healthcare systems. To date, most research on MLTCs has been conducted in primary care or the general population with comparatively little work undertaken in the hospital setting.

Purpose

To describe the rationale and content of ADMISSION: a four-year UK Research and Innovation and National Institute of Health and Care Research funded interdisciplinary programme that seeks, in partnership with public contributors, to transform care for people living with MLTCs admitted to hospital.

Research design

Based across five UK academic centres, ADMISSION combines expertise in clinical medicine, epidemiology, informatics, computing, biostatistics, social science, genetics and care pathway mapping to examine patterns of conditions, mechanisms, consequences and pathways of care for people with MLTCs admitted to hospital.

Data collection

The programme uses routinely collected electronic health record data from large UK teaching hospitals, population-based cohort data from UK Biobank and routinely collected blood samples from The Scottish Health Research Register and Biobank (SHARE). These approaches are complemented by focused qualitative work exploring the perspectives of healthcare professionals and the lived experience of people with MLTCs admitted to hospital.

Conclusion

ADMISSION will provide the necessary foundations to develop novel ways to prevent and treat MLTCs and their consequences in people admitted to hospital and to improve care systems and the quality of care for this underserved group.

Chronic illness experience in the context of resource-limited settings: a concept analysis

AIM

This review describes the ways in which individuals experience chronic illnesses in resource-limited settings; to define the concept and understand its attributes, antecedents and consequences.

METHODS

A comprehensive analysis of the databases CINAHL, PubMed and Google Scholar was conducted. During literature search the following limits were applied: articles published in English with available full-text; articles that focused on living with chronic illness in adults from the patient's perspective.

RESULTS

The following three attributes of chronic illness experience were identified: transformational experience, acceptance and self-management. Prominent predisposing factors (antecedents) were: genetic inheritance, malnutrition and poverty, high levels of stress and unhealthy lifestyle. The most dominant consequences were as follows: impact on quality of life; self-management burden; burden to others and economic stressors.

CONCLUSIONS

The findings underscore the need for health-care professionals to understand the chronic illness experience in the context of resource-limited settings and its consequences. The greater insights into the concept of chronic illness experience in resource-limited settings will guide nurses to support people in the realities of chronic illness experience in resource-limited settings in developing countries. This knowledge can guide nurses in providing competent care to chronically ill individuals, including meeting their individual needs with such illnesses.

The impact of place on multimorbidity: A systematic scoping review

Multimorbidity, commonly defined as the co-existence of two or more long-term conditions, is a major global public health challenge with significant impacts for health and social care systems. There is a substantial body of work identifying different individual- and household-level determinants of multimorbidity, yet the role of place-based characteristics in affecting multimorbidity remains limited. This systematic scoping review identifies place-based risk factors for multimorbidity and further synthesises the potential pathways explaining these relationships using longitudinal evidence. By systematically searching seven major databases, such as Medline, Embase, and Web of Science, using relevant search terms (e.g., MeSH) relating to place-based risk factors and multimorbidity, 76 out of 7761 studies were included for evidence synthesis. We include studies exploring the relationship between place-based risk factors and multimorbidity among the general population older than 18 years old in the setting of community-dwelling, primary, and secondary care. We identified 12 types of place-based risk factors, with the impacts of area-level deprivation/SES, pollution, and urban/rurality on multimorbidity being most frequently considered and with the most consistent findings, with people living in more deprived/low SES, highly polluted, or more urbanised areas having increased risks of multimorbidity. Further, the impact of these place-based risk factors on multimorbidity varied according to the operationalisation of the multimorbidity measure. We also identified that the impacts of other types of place-based factors on multimorbidity remain underexplored, such as social cohesion and greenspace. Finally, using these longitudinal findings, we propose a conceptual framework linking place and multimorbidity. We suggest that future studies explore a wider range of place-level environmental exposures and use more precise measures, exploit electronic health records to implement more consistent and reproducible measurements of multimorbidity, moreover, make greater use of longitudinal study designs or analytical approaches better suited to identifying causal processes.

Multimorbidity among the Indigenous population: A systematic review and meta-analysis

BACKGROUND

Multimorbidity, the concurrent presence of multiple chronic health conditions in an individual, represents a mounting public health challenge. Chronic illnesses are prevalent in the Indigenous populations, which contributes to multimorbidity. However, the epidemiology of multimorbidity in this population is not well studied. This review aimed to elucidate the extent, determinants, consequences, and prevention of multimorbidity within Indigenous populations globally, contrasting findings with non-Indigenous populations.

METHODS

Adhering to the PRISMA guidelines, this systematic review assimilated peer-reviewed articles and grey literature, focusing on the prevalence, determinants, implications, and preventive strategies of multimorbidity in global Indigenous populations. Emphasis was given to original, English-language, full-text articles, excluding editorials, and conference abstracts.

FINDINGS

Of the 444 articles identified, 13 met the inclusion criteria. Five studies are from Australia, and the rest are from the USA, Canada, New Zealand, and India. The study indicated a higher multimorbidity prevalence among Indigenous populations, with consistent disparities observed across various age groups. Particularly, Indigenous individuals exhibited a 2-times higher likelihood of multimorbidity compared to non-Indigenous populations. Noteworthy findings underscored the elevated severity of certain comorbid conditions, especially strokes, within Indigenous groups, with further revelations highlighting their significant pairing with conditions such as heart diseases and diabetes.

INTERPRETATION

The findings affirm the elevated burden of multimorbidity among Indigenous populations. Prevalence and risk of developing multimorbidity are significantly higher in this population compared to their non-Indigenous counterparts. Future research should prioritize harmonized research methodologies, fostering insights into the multimorbidity landscape, and promoting strategies to address health disparities in Indigenous populations.

Social Deprivation and Multimorbidity Among Community-Based Health Center Patients in the United States

Introduction

Multimorbidity - having 2 or more chronic diseases - is a national public health concern that entails burdensome and costly care for patients, their families, and public health programs. Adults residing in socially deprived areas often have limited access to social and material resources. They also experience a greater multimorbidity burden.

Methods

We conducted a retrospective cohort analysis of electronic health record (EHR) data from 678 community-based health centers (CHCs) in 27 states from the Accelerating Data Value Across a National Community Health Center (ADVANCE) Network, a clinical research network, from 2012-2019. We used mixed-effects Poisson regression to examine the relationship of area-level social deprivation (eg, educational attainment, household income, unemployment) to chronic disease accumulation among a sample of patients aged 45 years or older (N = 816,921) residing across 9,362 zip code tabulation areas and receiving care in safety-net health organizations.

Results

We observed high rates of chronic disease among this national sample. Prevalence of multimorbidity varied considerably by geographic location, both within and between states. People in more socially deprived areas with Social Deprivation Index (SDI) scores in quartiles 2, 3, and 4 had greater initial chronic disease counts - 17.1%, 17.7%, and 18.0%, respectively - but a slower rate of accumulation compared with people in the least-deprived quartile. Our findings were consistent for models of the composite SDI and those evaluating disaggregated measures of area-level educational attainment, household income, and unemployment.

Conclusion

Social factors play an important role in the development and progression of multimorbidity, which suggests that an assessment and understanding of area-level social deprivation is necessary for developing public health strategies to address multimorbidity.

Resilience among older adults with multimorbidity using the Connor-Davidson scale in the Canadian Longitudinal Study on Aging: health behaviour, socio-economic, and social support predictors

OBJECTIVE

Multimorbidity is recognized as a serious health condition faced by a majority of older adults. Research investigating adaptive responses to multimorbidity, termed multimorbidity resilience, has been growing. This paper examines protective and risk factors, with a focus on health behaviours, socio-economic resources, and social support using an established measure of resilience (Connor-Davidson Resilience Scale) among older adults, focusing on older persons with two or more concurrent chronic conditions.

METHODS

Using Baseline (2011-2015), Follow-up One (2015-2018), and Follow-up Two (2018-2021) data from the Comprehensive Cohort of the Canadian Longitudinal Study on Aging, we tested hypotheses using 13,064 participants aged 65 years and older, who completed all waves and reported two or more of 27 chronic conditions, for the full sample of multimorbid individuals and three multimorbidity clusters: Cardiovascular/Metabolic, Musculoskeletal, and Mental Health. Associations between protective and risk factors and resilience were examined using linear regression to model the Connor-Davidson resilience scale, adjusting for illness context and social determinants of health.

RESULTS

Among all multimorbid individuals, the strongest associations with resilience were found for higher self-rated health, greater sleep satisfaction, better appetite, higher household income, more relatives and friends, being overweight (compared to normal weight), fewer housing problems, and fewer skipped meals. Weaker associations were found for non-smokers, less alcohol consumption, less pain, sedentary behaviour, being non-married (compared to married), and among Canadian born (compared to foreign). The analyses for the three multimorbidity clusters were largely replicated for the three multimorbidity clusters, but with some nuances depending on the cluster.

DISCUSSION

This research provides confirmatory evidence for several protective and risk factors affecting the ability to cope and recover from multimorbidity adversity among older adults. There are consistent patterns for the multimorbidity disease clusters, but some distinct relationships arise that are worthy of attention. The implications of the findings for modifiable health behaviours and socio-economic factors are discussed for their public health and clinical relevance.

The association between off- and on-premise alcohol outlet density and 100% alcohol-attributable emergency department visits by neighbourhood-level socioeconomic status in Ontario, Canada

Alcohol availability is positively associated with alcohol use and harms, but the influence of socioeconomic status (SES) on these associations is not well established. This population-based cross-sectional study examined neighbourhood-level associations between physical alcohol availability (measured as off- and on-premise alcohol outlet density) and 100% alcohol-attributable emergency department (ED) visits by neighbourhood SES in Ontario, Canada from 2017 to 2019 (n = 19,740). A Bayesian spatial modelling approach was used to assess associations and account for spatial autocorrelation, which produced risk ratios (RRs) and 95% credible intervals (95% CrI). Each additional off-premise alcohol outlet in a neighbourhood was associated with a 3% increased risk of alcohol-attributable ED visits in both men (RR = 1.03, 95%CrI: 1.02-1.04) and women (RR = 1.03, 95% CrI: 1.02-1.04). Positive associations were also observed between on-premise alcohol outlet density and alcohol-attributable ED visits, although effect sizes were small. A disproportionately greater association with ED visits was observed with increasing alcohol outlet density in the lowest compared to higher SES neighbourhoods. Reducing physical alcohol availability may be an important policy lever for reducing alcohol harm and alcohol-attributable health inequities.

Reporting and representation of underserved groups in intervention studies for patients with multiple long-term conditions: a systematic review

OBJECTIVES

Globally, there is a growing number of people who are living with multiple long-term conditions (MLTCs). Due to complex management needs, it is imperative that research consists of participants who may benefit most from interventions. It is well documented that ethnic minority groups and lower socioeconomic status (SES) groups are at an increased risk of developing MLTCs. Therefore, the aim of this systematic review was to determine the level of reporting and representation of underserved groups (ethnic minority and low SES) in intervention studies addressing MLTCs.

DESIGN

Systematic review. Four databases including Cochrane Library, MEDLINE, CINAHL and Scopus were searched for intervention studies from North America or Europe published between January 1990 and July 2023.

SETTING

Hospital and community-based interventions. We included interventional studies focusing on improving MLTC-related outcomes.

PARTICIPANTS

Patients with MLTCs.

MAIN OUTCOME MEASURES

Total number of studies reporting on ethnicity and SES. Number and proportion of studies reporting by ethnic/SES group.

RESULTS

Thirteen studies met the inclusion criteria. Only 4 of 13 studies (31%) recorded and reported ethnicity information. Of these four studies that reported on ethnicity, three studies consisted of primarily White participants. Ethnic minority groups were underrepresented, but one study included a majority of African American participants. Moreover, 12 of 13 studies (92%) reported on SES with income and educational level being the primary measures used. SES representation of higher deprivation groups was varied due to limited data.

CONCLUSIONS

For ethnicity, there was a lack of reporting, and ethnic minority groups were underrepresented in intervention studies. For SES, there was a high level of reporting but the proportion of study samples from across the spectrum of SES varied due to the variety of SES measures used. Findings highlight a need to improve the reporting and representation of ethnic minority groups and provide more detailed information for SES through using consistent measures (e.g. education, income and employment) to accurately determine the distribution of SES groups in intervention studies of people with MLTCs.

The impact of adverse childhood experiences on multimorbidity: a systematic review and meta-analysis

BACKGROUND

Adverse childhood experiences (ACEs) have been implicated in the aetiology of a range of health outcomes, including multimorbidity. In this systematic review and meta-analysis, we aimed to identify, synthesise, and quantify the current evidence linking ACEs and multimorbidity.

METHODS

We searched seven databases from inception to 20 July 2023: APA PsycNET, CINAHL Plus, Cochrane CENTRAL, Embase, MEDLINE, Scopus, and Web of Science. We selected studies investigating adverse events occurring during childhood (< 18 years) and an assessment of multimorbidity in adulthood (≥ 18 years). Studies that only assessed adverse events in adulthood or health outcomes in children were excluded. Risk of bias was assessed using the ROBINS-E tool. Meta-analysis of prevalence and dose-response meta-analysis methods were used for quantitative data synthesis. This review was pre-registered with PROSPERO (CRD42023389528).

RESULTS

From 15,586 records, 25 studies were eligible for inclusion (total participants = 372,162). The prevalence of exposure to ≥ 1 ACEs was 48.1% (95% CI 33.4 to 63.1%). The prevalence of multimorbidity was 34.5% (95% CI 23.4 to 47.5%). Eight studies provided sufficient data for dose-response meta-analysis (total participants = 197,981). There was a significant dose-dependent relationship between ACE exposure and multimorbidity (p < 0.001), with every additional ACE exposure contributing to a 12.9% (95% CI 7.9 to 17.9%) increase in the odds for multimorbidity. However, there was heterogeneity among the included studies (I2 = 76.9%, Cochran Q = 102, p < 0.001).

CONCLUSIONS

This is the first systematic review and meta-analysis to synthesise the literature on ACEs and multimorbidity, showing a dose-dependent relationship across a large number of participants. It consolidates and enhances an extensive body of literature that shows an association between ACEs and individual long-term health conditions, risky health behaviours, and other poor health outcomes.

Trajectories in long-term condition accumulation and mortality in older adults: a group-based trajectory modelling approach using the English Longitudinal Study of Ageing

OBJECTIVES

To classify older adults into clusters based on accumulating long-term conditions (LTC) as trajectories, characterise clusters and quantify their associations with all-cause mortality.

DESIGN

We conducted a longitudinal study using the English Longitudinal Study of Ageing over 9 years (n=15 091 aged 50 years and older). Group-based trajectory modelling was used to classify people into clusters based on accumulating LTC over time. Derived clusters were used to quantify the associations between trajectory memberships, sociodemographic characteristics and all-cause mortality by conducting regression models.

RESULTS

Five distinct clusters of accumulating LTC trajectories were identified and characterised as: 'no LTC' (18.57%), 'single LTC' (31.21%), 'evolving multimorbidity' (25.82%), 'moderate multimorbidity' (17.12%) and 'high multimorbidity' (7.27%). Increasing age was consistently associated with a larger number of LTCs. Ethnic minorities (adjusted OR=2.04; 95% CI 1.40 to 3.00) were associated with the 'high multimorbidity' cluster. Higher education and paid employment were associated with a lower likelihood of progression over time towards an increased number of LTCs. All the clusters had higher all-cause mortality than the 'no LTC' cluster.

CONCLUSIONS

The development of multimorbidity in the number of conditions over time follows distinct trajectories. These are determined by non-modifiable (age, ethnicity) and modifiable factors (education and employment). Stratifying risk through clustering will enable practitioners to identify older adults with a higher likelihood of worsening LTC over time to tailor effective interventions to prevent mortality.

Living on low-incomes with multiple long-term health conditions: A new method to explore the complex interaction between finance and health

People on low-incomes in the UK develop multiple long-term health conditions over 10 years earlier than affluent individuals. Financial diaries -new to public health- are used to explore the lived experiences of financially-vulnerable individuals, diagnosed with at least one long-term condition, living in two inner-city London Boroughs. Findings show that the health status of these individuals is a key barrier to work opportunities, undermining their income. Their precarious and uncertain financial situation, sometimes combined with housing issues, increased stress and anxiety which, in turn, contributed to further deteriorate participants' health. Long-term health conditions limited the strategies to overcome moments of financial crisis and diarists frequently used credit to cope. Restrictions to access reliable services and timely support were connected to the progression of multiple long-term conditions. Models that integrate healthcare, public health, welfare and financial support are needed to slow down the progression from one to many long-term health conditions.

Racial inequalities in the development of multimorbidity of chronic conditions: results from a Brazilian prospective cohort

BACKGROUND

The occurrence of multimorbidity and its impacts have differentially affected population subgroups. Evidence on its incidence has mainly come from high-income regions, with limited exploration of racial disparities. This study investigated the association between racial groups and the development of multimorbidity and chronic conditions in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil).

METHODS

Data from self-reported white, brown (pardos or mixed-race), and black participants at baseline of ELSA-Brasil (2008-2010) who were at risk for multimorbidity were analysed. The development of chronic conditions was assessed through in-person visits and self-reported diagnosis via telephone until the third follow-up visit (2017-2019). Multimorbidity was defined when, at the follow-up visit, the participant had two or more morbidities. Cumulative incidences, incidence rates, and adjusted incidence rate ratios (IRRs) were estimated using Poisson models.

RESULTS

Over an 8.3-year follow-up, compared to white participants: browns had a 27% greater incidence of hypertension and obesity; and blacks had a 62% and 45% greater incidence, respectively. Blacks also had 58% more diabetes. The cancer incidence was greater among whites. Multimorbidity affected 41% of the participants, with a crude incidence rate of 57.5 cases per 1000 person-years (ranging from 56.3 for whites to 63.9 for blacks). Adjusted estimates showed a 20% higher incidence of multimorbidity in black participants compared to white participants (IRR: 1.20; 95% CI: 1.05-1.38).

CONCLUSIONS

Significant racial disparities in the risk of chronic conditions and multimorbidity were observed. Many associations revealed a gradient increase in illness risk according to darker skin tones. Addressing fundamental causes such as racism and racial discrimination, alongside considering social determinants of health, is vital for comprehensive multimorbidity care. Intersectoral, equitable policies are essential for ensuring health rights for historically marginalized groups.

Service innovations for people with multiple long-term conditions: reflections of a rapid evaluation team

Background

People living with multiple long-term conditions represent a significant concern for National Health Service policy and practice, and their care is a major theme in the 2019 National Health Service Long Term Plan. The Birmingham RAND and Cambridge Rapid Evaluation Centre team has undertaken a thematic synthesis of the 10 evaluations it has conducted from 2018 to 2023, exploring the needs, priorities and implications for people with multiple long-term conditions.

Objectives

The aims for this overarching study were to: (1) build a body of learning about service innovations in primary and community settings for people of all ages with multiple long-term conditions, focused on questions that matter most to people with multimorbidity; and (2) develop methodological insights about how rapid evaluation can be used to inform the scoping, testing and implementation of service innovations for people with multiple long-term conditions.

Design

The focus on multiple long-term conditions came from a Birmingham RAND and Cambridge Rapid Evaluation Centre prioritisation process undertaken in 2018 using James Lind Alliance methods. Cross-analysis of the findings from the 10 individual rapid evaluations was supplemented by (1) building aspects of multimorbidity into the design of later evaluations; (2) interviewing national and regional stakeholders (n=19) working in or alongside integrated care systems; (3) undertaking a rapid review of evidence on remote monitoring for people with multiple long-term conditions (19 papers included); and (4) testing overall insights with organisations representing patients and carers through a patient, public and professional engagement workshop with 10 participants plus members of the research team.

Results

While living with multiple long-term conditions is common and is the norm for people over the age of 50 using health and care services, it is not often a focus of health service provision or innovation, nor of research and evaluation activity. We discuss six themes emerging from the totality of the study: (1) our health system is mainly organised around single conditions and not multiple long-term conditions; (2) research calls and studies usually focus on single conditions and associated services; (3) building opportunities for engaged, informed individuals and carers and improved self-management; (4) the importance of measures that matter for patients and carers; (5) barriers to developing and implementing service innovations for people with multiple long-term conditions; and (6) what is needed to make patients with multiple long-term conditions a priority in healthcare planning and delivery.

Limitations

Care of people with multiple long-term conditions was not the principal focus of several of the rapid evaluations. While this was a finding in itself, it limited our learning about designing and implementing, as well as methodological approaches to evaluating, service innovations for people with multiple long-term conditions.

Conclusions

Through a thematic analysis of the portfolio of evaluations, we have deduced a set of suggested implications for how the needs of people with multiple long-term conditions can be better embedded in policy, research and practice.

Future work

Areas of uncertainty related to the care of people with multiple long-term conditions should be further explored, including developing and testing measures of patient experience of (un)co-ordinated care across settings, and interrogating the experience of health and care staff when working with people with multiple long-term conditions, to understand what works.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR134284) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 15. See the NIHR Funding and Awards website for further award information.

Patient and public involvement in the development of health services: Engagement of underserved populations in a quality improvement programme for inflammatory bowel disease using a community-based participatory approach

INTRODUCTION

Involving people with lived experience is fundamental to healthcare development and delivery. This is especially true for inflammatory bowel disease (IBD) services, where holistic and personalised models of care are becoming increasingly important. There is, however, a significant lack of representation of underserved and diverse groups in IBD research, and there are significant barriers to healthcare access and utilisation among minority groups in IBD. IBD centres need to be aware of these experiences to address barriers via service changes, improve interactions with local communities and promote meaningful engagement for improved health outcomes.

METHODS

A pragmatic community-based approach was taken to engage with leaders and members of underserved groups across 11 workshops representing Roma, Afro-Caribbean, people of African descent and the wider black, Asian and minority ethnic (BAME) communities, Muslim women, refugee community members, deprived areas of South Yorkshire, LGBTQ+ and deaf populations. Thematic analysis of field notes identified patterns of attention across the community groups and where improvements to services were most frequently suggested.

RESULTS

Findings demonstrated several barriers experienced to healthcare access and utilisation, including language accessibility, staff attitudes and awareness, mental health and stigma, continuity of support, and practical factors such as ease of service use and safe spaces. These barriers acted as a lever to co-producing service changes that are responsive to the health and social care needs of these groups.

CONCLUSIONS

Engaging with people from a range of communities is imperative for ensuring that service improvements in IBD are accessible and representative of individual needs and values.

PATIENT OR PUBLIC CONTRIBUTION

Local community leaders and members of community groups actively participated in the co-design and development of improvements to the IBD service for a local hospital. Their contributions further informed a pilot process for quality improvement programmes in IBD centres.

Promoting Social Participation in the Primary Care Field: An Ecological Study on the Potential Reduction of Multimorbidity Prevalence

BACKGROUND

No municipal-level study has elucidated the social determinants associated with multimorbidity prevalence (MP).

OBJECTIVE

This article aimed to determine the differences in MP among municipalities and investigate factors associated with such differences through an ecological study of data obtained from a nationwide survey. This article focused on social participation and household income, which are associated with single chronic diseases, such as hypertension.

METHODS

Study design was a cross sectional study, which used the data from the Japan Gerontological Evaluation Study, a population-based gerontological study among functionally independent older adults aged ≥65 years in Japan. Overall, 152 212 participants from 2016 to 2017 across 91 municipalities were included in the final analysis. Multiple regression analysis was performed with MP as objective variable; social participation or household income were explanatory variables, and education, population density, and health check-ups were adjustment variables.

RESULTS

Intermunicipal differences in MP were 28.4% to 43.1% and 23.2% to 38.8% among men and women, respectively. Significant negative correlation was observed between MP and proportion of social participation (non-standardized coefficient [B] = -.18 for men and women). A significant positive correlation was noted between MP and equivalent household income of ≤2 million yen in women (B = .21).

CONCLUSION

Considerable differences in MP existed among municipalities. Areas with high proportion of social participation showed significantly lower MP. Considering the difficulty in managing multimorbidity within the primary care field and limited evidence on effective interventions, community-level interventions encouraging social participation among older individuals might reduce MP. Primary care physicians should consider a community health approach for multimorbidity.

[Primary Care Inequalities to the Disadvantage of the Population of Socially Deprived Urban Areas: A Case Study of Essen, Germany]

Background As a large city in the middle of a metropolitan area, the city of Essen is characterized by strong social segregation and a north-south divide in the social status of its population. The conventional demand planning does not take such strong disparities within a planning unit into account. The present study aims to analyze the distribution of primary care structures using the example of two large urban areas within the city of Essen and to identify perspectives for strengthening primary care in disadvantaged urban areas. Methods First, a secondary data analysis was carried out at the district level and the study area Essen North (258,790 residents), consisting of 19 districts, was defined on the basis of two inclusion criteria - 1. location of the district north of the A40 freeway and 2. a mean subsistence rate>17.20 percent (average value of the city of Essen). Subsequently the study area was compared with the rest of the city (332,242 residents) with regard to the indicators a) social status, and b) available general practioners and pediatricians. The data of the selected indicators is based on the social reporting of the city of Essen and the "Online Practice Search" (Online-Praxissuche) of the Association of Statutory Health Insurance Physicians North Rhine. The resulting database (last update: 10/20212) was then evaluated at the district level and the primary care situation of the two urban areas was compared. Results The results revealed a significantly lower primary care coverage in the socially disadvantaged study area Essen North by about 25 percent for general practioners and by almost half for pediatricians. Thus, higher social disadvantage was associated with poorer access to primary care close to home, especially for children and adolescents. Conclusion The distribution of primary care providers in the city of Essen increases the risk of contributing to the manifestation of geographic disparities and health inequalities. The existing planning system in particular is not suitable for addressing the threatening or already existing undersupply of primary health care to the population in disadvantaged urban districts.

Epidemiology, mortality, and health service use of local-level multimorbidity patterns in South Spain

Multimorbidity -understood as the occurrence of chronic diseases together- represents a major challenge for healthcare systems due to its impact on disability, quality of life, increased use of services and mortality. However, despite the global need to address this health problem, evidence is still needed to advance our understanding of its clinical and social implications. Our study aims to characterise multimorbidity patterns in a dataset of 1,375,068 patients residing in southern Spain. Combining LCA techniques and geographic information, together with service use, mortality, and socioeconomic data, 25 chronicity profiles were identified and subsequently characterised by sex and age. The present study has led us to several findings that take a step forward in this field of knowledge. Specifically, we contribute to the identification of an extensive range of at-risk groups. Moreover, our study reveals that the complexity of multimorbidity patterns escalates at a faster rate and is associated with a poorer prognosis in local areas characterised by lower socioeconomic status. These results emphasize the persistence of social inequalities in multimorbidity, highlighting the need for targeted interventions to mitigate the impact on patients' quality of life, healthcare utilisation, and mortality rates.

Usefulness of SPISE Index for Screening and Detection of Early Stages of Insulin Resistance among Chilean Young Adults

BACKGROUND

As the gold standard test to quantify insulin resistance (IR) involves intravenous insulin loading and repeated blood glucose monitoring, many indexes have been developed for IR assessment for convenience.

OBJECTIVE

The objective of this study was to evaluate the agreement of the Single-Point Insulin Sensitivity Estimator (SPISE) by comparing it with the homeostasis model assessment of insulin resistance (HOMA-IR) in identifying IR.

METHOD

Data came from the ongoing LIMACHE BIRTH COHORT. 1,948 individuals (aged 22-28 years) were studied. We performed an agreement plot called a Bangdiwala's Observer Agreement to evaluate patterns in departures from agreement in ordinal categorical variables.

RESULTS

According to the Bangdiwala-Weighted statistics, we found that the agreement between both indexes was 0.14; this value would be considered a slight agreement. Thus, we found bias in the marginal distributions, and we noticed that the SPISE has a bias toward the central quintiles of the index.

CONCLUSIONS

The identification of IR in young adult individuals by the SPISE index has slight agreement with HOMA-IR. Therefore, caution would be taken when considering SPISE index among young Chilean adults.

What can death records tell us about multimorbidity?

BACKGROUND

Multimorbidity has been measured from many data sources which show that prevalence increases with age and is usually greater among women than men and in more recent periods. Analyses of multiple cause of death data have shown different patterns of multimorbidity associated with demographic and other characteristics.

METHODS

Deaths in Australia among over 1.7 million decedents aged 55+ were stratified into three types: medically certified deaths, coroner-referred deaths with natural underlying causes and coroner-referred deaths with external underlying causes. Multimorbidity was measured by prevalence of ≥2 causes and analysed over three periods based on administrative changes: 2006-2012, 2013-2016 and 2017-2018. Poisson regression was used to examine the influence of gender, age and period.

RESULTS

The prevalence of deaths with multimorbidity was 81.0% for medically certified deaths, 61.1% for coroner-referred deaths with natural underlying causes and 82.4% for coroner-referred deaths with external underlying causes. For medically certified deaths, multimorbidity increased with age: incidence rate ratio (IRR 1.070, 95% CI 1.068, 1.072) was lower for women than men (0.954, 95% CI 0.952, 0.956) and changed little over time. For coroner-referred deaths with natural underlying causes, multimorbidity showed the expected pattern increasing with age (1.066, 95% CI 1.062, 1.070) and being higher for women than men (1.025, 95% CI 1.015, 1.035) and in more recent periods. For coroner-referred deaths with external underlying causes, there were marked increases over time that differed by age group due to changes in coding processes.

CONCLUSION

Death records can be used to examine multimorbidity in national populations but, like other data sources, how the data were collected and coded impacts the conclusions.

[Factors associated with the risk of hospitalization and death related to SARS-CoV-2 infection.]

OBJECTIVE

COVID-19 has tried out global health causing high mortality. There are some risk factors that associate greater severity and mortality from COVID-19; but their individual impact is unknown yet. There are also no fixed criteria for hospital admission. For this reason, this study aimed to analyze the factors associated with the severity of COVID-19 and create predictive models for the risk of hospitalization and death due to COVID-19.

METHODS

A descriptive retrospective cohort study was made in Talavera de la Reina (Toledo, Spain). Data were collected through computerized records of Primary Care, Emergencies and Hospitalization. The sample consisted of 275 patients over eighteen years old diagnosed with COVID-19 in a centralized laboratory from March 1st to May 31st, 2020. Analysis was carried on using SPSS, creating two predictive models for the risk of hospitalization and death using linear regression.

RESULTS

The probability of hospitalization increased independently with polypharmacy (OR 1.086; CI95% 1.009-1.169), the Charlson index (OR 1.613; CI95% 1.158-2.247), the history of acute myocardial infarction (AMI) (OR 4.358; 95% CI 1.114-17.051) and the presence of COVID symptoms (OR 7.001; 95% CI 2.805-17.475). The probability of death was independently associated with age, increasing 8.1% (OD 1.081; 95% CI 1.054- 1.110) for each year of the patient.

CONCLUSIONS

Comorbidity, polypharmacy, history of AMI and the presence of COVID-19 symptoms predict the risk of hospitalization. The age of individuals predicts the risk of death. Detecting patients at high risk of hospitalization and death allows us to define the target population and define measures to implement.

Trajectories of multiple long-term conditions and mortality in older adults: A retrospective cohort study using English Longitudinal Study of Ageing (ELSA)

Objectives

To classify older adults with MLTC into clusters based on accumulating conditions as trajectories over time, characterise clusters and quantify associations between derived clusters and all-cause mortality.

Design

We conducted a retrospective cohort study using the English Longitudinal Study of Ageing (ELSA) over nine years (n=15,091 aged 50 years and older). Group-based trajectory modelling was used to classify people into MLTC clusters based on accumulating conditions over time. Derived clusters were used to quantify the associations between MLTC trajectory memberships, sociodemographic characteristics, and all-cause mortality.

Results

Five distinct clusters of MLTC trajectories were identified and characterised as: "no-LTC" (18.57%), "single-LTC" (31.21%), "evolving MLTC" (25.82%), "moderate MLTC" (17.12%), and "high MLTC" (7.27%). Increasing age was consistently associated with an increased number of MLTC. Female sex (aOR = 1.13; 95%CI 1.01 to 1.27) and ethnic minority (aOR = 2.04; 95%CI 1.40 to 3.00) were associated with the "moderate MLTC" and "high MLTC" clusters, respectively. Higher education and paid employment were associated with a lower likelihood of progression over time towards an increased number of MLTC. All the clusters had higher all-cause mortality than the "no-LTC" cluster.

Conclusions

The development of MLTC and the increase in the number of conditions over time follow distinct trajectories. These are determined by non-modifiable (age, sex, ethnicity) and modifiable factors (education and employment). Stratifying risk through clustering will enable practitioners to identify older adults with a higher likelihood of worsening MLTC over time to tailor effective interventions.

Chronic Disease in Low-Resource Settings: Prevention and Management Throughout the Continuum of Care-A Call for Papers

Multimorbidity, defined as the presence of two or more chronic conditions in an individual, has become a global public health challenge [...].

Life-course fertility and multimorbidity among middle-aged and elderly women in China: Evidence from China health and retirement longitudinal study

Background

Multimorbidity has become an important public health problem in China, especially among middle-aged and elderly women. Few studies have been reported on the association between multimorbidity and female fertility, which is an important stage in the life course. This study aimed to explore the association between multimorbidity and fertility history among middle-aged and elderly women in China.

Methods

Data from 10,182 middle-aged and elderly female participants in the China Health and Retirement Longitudinal Study (CHARLS) in 2018 were used in this study. Multimorbidity was defined as the presence of at least two or more chronic conditions. Logistic regression analysis, negative binomial regression analysis, and restrictive cubic splines (RCSs) were used to analyze the relationship between female fertility history and multimorbidity or the number of chronic conditions. Multivariable linear regression was used to analyze the relationship between female fertility history and multimorbidity pattern factor scores.

Results

The results of this study showed that high parity and early childbearing were significantly associated with an increased risk of multimorbidity and an increased number of chronic conditions among middle-aged and elderly women in China. Late childbearing was significantly associated with reduced risk of multimorbidity and lessened diseases. Parity and age of first childbirth were significantly correlated with the odds of multimorbidity. The association between fertility history and multimorbidity was found to be influenced by age and urban-rural dual structure. Women with high parity tend to have higher factor scores of cardiac-metabolic, visceral-arthritic, and respiratory-psychiatric patterns. Women with early childbearing tended to have higher factor scores of the visceral-arthritic pattern and those with late childbearing tended to have lower factor scores of the cardiac-metabolic pattern.

Conclusion

Fertility history has a significant effect on multimorbidity in the middle and later lives of Chinese women. This study is of great importance for reducing the prevalence of multimorbidity among Chinese women through their life course and promoting health during their middle and later lives.

Patterns and Determinants of Multimorbidity in Older Adults: Study in Health-Ecological Perspective

(1) Background: Multimorbidity has become one of the key issues in the public health sector. This study aims to explore the patterns and health-ecological factors of multimorbidity in China to propose policy recommendations for the management of chronic diseases in the elderly. (2) Methods: A multi-stage random sampling method was used to conduct a questionnaire survey on 3637 older adults aged 60 and older in Shanxi, China. Association rule mining analysis (ARM) and network analysis were applied to analyze the patterns of multimorbidity. The health-ecological model was adopted to explore the potential associated factors of multimorbidity in a multidimensional perspective. A hierarchical multiple logistic model was employed to investigate the association strengths reflected by adjusted odds ratios and 95% confidence. (3) Results: Multimorbidity occurred in 20.95% of the respondents. The graph of network analysis showed that there were 6 combinations of chronic diseases with strong association strengths and 14 with moderate association strengths. The results of the ARM were similar to the network analysis; six dyadic chronic disease combinations and six triadic ones were obtained. Hierarchical multiple logistic regression indicated that innate personal traits (age, history of genetics, and body mass index), behavioral lifestyle (physical activity levels and medication adherence), interpersonal network (marital status), and socioeconomic status (educational level) were the common predictors of multimorbidity for older adults, among which, having no family history was found to be a relative determinant as a protective factor for multimorbidity after controlling the other covariates. (4) Conclusions: multimorbidity was prevalent in older adults and most disease combinations are associated with hypertension, followed by diabetes. This shows that diabetes and hypertension have a high prevalence among older adults and have a wide range of associations with other chronic diseases. Exploring the patterns and associated factors of multimorbidity will help the country prevent complications and avoid the unnecessary use of the health service, adopting an integrated approach to managing multimorbidity rather than an individual disease-specific approach and implementing different strategies according to the location of residence.

Household and area determinants of emergency department attendance and hospitalisation in people with multimorbidity: a systematic review

OBJECTIVES

Multimorbidity is one of the greatest challenges facing healthcare internationally. Emergency department (ED) attendance and hospitalisation rates are higher in people with multimorbidity, but most research focuses on associations with individual characteristics, ignoring household or area mediators of service use.

DESIGN

Systematic review reported using the synthesis without meta-analysis framework.

DATA SOURCES

Twelve electronic databases (1 January 2000-21 September 2021): MEDLINE/OVID, Embase, Global Health, PsycINFO, ASSIA, CAB Abstracts, Science Citation Index Expanded/ISI Web of Science, Scopus, Cumulative Index to Nursing and Allied Health Literature, Sociological Abstracts, the Cochrane Library, and OpenGrey.

ELIGIBILITY CRITERIA

Adults aged ≥16 years, with multimorbidity. Exposure(s) were household and/or area determinants of health. Outcomes were ED attendance and/or hospitalisation. The literature search was limited to publications in English.

DATA EXTRACTION AND SYNTHESIS

Independent double screening of titles and abstracts to select relevant full-text studies. Methodological quality was assessed using an adaptation of the Newcastle-Ottawa Quality Assessment Scale tool. Given high study heterogeneity, narrative synthesis was performed.

RESULTS

After deduplication, 10 721 titles and abstracts were screened, and 142 full-text articles were reviewed, of which 10 were eligible for inclusion. In people with multimorbidity, household food insecurity was associated with hospitalisation (OR 1.58 (95% CI 1.06 to 2.36) in concordant multimorbidity). People with multimorbidity living in the most versus least deprived areas attended ED more frequently (8.9% (95% CI 8.6 to 9.1) in most versus 6.3% (95% CI 6.1 to 6.6) in least), had higher rates of hospitalisation (26% in most versus 22% in least), and higher probability of hospitalisation (6.4% (95% CI 5.8 to 7.2) in most versus 4.2% (95% CI 3.8 to 4.7) in least). There was non-conclusive evidence that household income is associated with ED attendance and hospitalisation. No statistically significant relationships were found between marital status, living with others with multimorbidity, or rurality with ED attendance or hospitalisation.

CONCLUSIONS

There is some evidence that household and area contexts mediate associations of multimorbidity with ED attendance and hospitalisation, but firm conclusions are constrained by the small number of studies published and study design heterogeneity. Further research is required on large population samples using robust analytical methods.

PROSPERO REGISTRATION NUMBER

CRD42021283515.

Family-Level Multimorbidity among Older Adults in India: Looking through a Syndemic Lens

Most evidence on multimorbidity is drawn from an individual level assessment despite the fact that multimorbidity is modulated by shared risk factors prevailing within the household environment. Our study reports the magnitude of family-level multimorbidity, its correlates, and healthcare expenditure among older adults using data from the Longitudinal Ageing Study in India (LASI), wave-1. LASI is a nationwide survey amongst older adults aged ≥45 years conducted in 2017-2018. We included (n = 22,526) families defined as two or more members coresiding in the same household. We propose a new term, "family-level multimorbidity", defined as two or more members of a family having multimorbidity. Multivariable logistic regression was used to assess correlates, expressed as adjusted odds ratios with a 95% confidence interval. Family-level multimorbidity was prevalent among 44.46% families, whereas 41.8% had conjugal multimorbidity. Amongst siblings, 42.86% reported multimorbidity and intergenerational (three generations) was 46.07%. Family-level multimorbidity was predominantly associated with the urban and affluent class. Healthcare expenditure increased with more multimorbid individuals in a family. Our findings depict family-centred interventions that may be considered to mitigate multimorbidity. Future studies should explore family-level multimorbidity to help inform programs and policies in strategising preventive as well as curative services with the family as a unit.

Multimorbidity

Multimorbidity (two or more coexisting conditions in an individual) is a growing global challenge with substantial effects on individuals, carers and society. Multimorbidity occurs a decade earlier in socioeconomically deprived communities and is associated with premature death, poorer function and quality of life and increased health-care utilization. Mechanisms underlying the development of multimorbidity are complex, interrelated and multilevel, but are related to ageing and underlying biological mechanisms and broader determinants of health such as socioeconomic deprivation. Little is known about prevention of multimorbidity, but focusing on psychosocial and behavioural factors, particularly population level interventions and structural changes, is likely to be beneficial. Most clinical practice guidelines and health-care training and delivery focus on single diseases, leading to care that is sometimes inadequate and potentially harmful. Multimorbidity requires person-centred care, prioritizing what matters most to the individual and the individual's carers, ensuring care that is effectively coordinated and minimally disruptive, and aligns with the patient's values. Interventions are likely to be complex and multifaceted. Although an increasing number of studies have examined multimorbidity interventions, there is still limited evidence to support any approach. Greater investment in multimorbidity research and training along with reconfiguration of health care supporting the management of multimorbidity is urgently needed.

Multimorbidity is associated with the income, education, employment and health domains of area-level deprivation in adult residents in the UK

Evidence suggests that there are social inequalities in multimorbidity, with a recent review indicating that area levels of deprivation are consistently associated with greater levels of multimorbidity. Definitions of multimorbidity, the most common of which is the co-occurrence of more than one long term condition, can include long term physical conditions, mental health conditions or both. The most commonly used measure of deprivation in England and Wales is the Index of Multiple Deprivation (IMD), an index of seven different deprivation domains. It is unclear which features of IMD may be mediating associations with multimorbidity. Thus, there may be associations because of the individual characteristics of those living in deprived areas, characteristics of the areas themselves or overlap in definitions. Data from over 25,000 participants (aged 16+) of Understanding Society (Wave 10, 1/2018–3/2020) were used to understand the most salient features of multimorbidity associated with IMD and whether physical or mental conditions are differentially associated with the seven domains of IMD. 24% of participants report multimorbidity. There is an increased prevalence of multimorbidity composed of only long-term physical conditions in the most deprived decile of deprivation (22%, 95% CI[19,25]) compared to the least deprived decile (16%, 95% CI[14,18]). Mental health symptoms but not reporting of conditions vary by decile of IMD. Associations with multimorbidity are limited to the health, income, education and employment domains of IMD. We conclude that multimorbidity represents a substantial population burden, particularly in the most deprived areas in England and Wales.

The epidemiology of multimorbidity in France: Variations by gender, age and socioeconomic factors, and implications for surveillance and prevention

Background

Robust public health and health system response to the increasing burden of multimorbidity worldwide requires detailed epidemiological examination of its key sociodemographic and geographic determinants. We investigated the role of gender, age and socioeconomic and geographic factors on multimorbidity (i.e., having two or more conditions) in the adult population in France and examined implications for surveillance and prevention.

Methods

We used data from two large nationwide representative surveys with cross-sectional and longitudinal health and socio-demographic indicators, conducted in France between 2008 and 2014. Morbidity counts and frequent dyads/triads of conditions independently impacting mortality, activity limitations, and perceived health were investigated with regard to differences in gender, age, socioeconomic (education, occupation and income) and geography (size of the urban unit and region).

Results

The component conditions of multimorbidity varied with gender and age. Women experienced multimorbidity 23–31% more frequently and at a younger age (5–15 years earlier) than men. Multimorbidity increased with age while its associations with most health indicators weakened with it. Multimorbidity was strongly and independently associated with socioeconomic indicators, with a strong inverse dose-response relationship with education, but less consistently with geographic factors.

Conclusions

Multimorbidity has diverse and variable components and impacts across gender and age. It is strongly associated with socioeconomic factors, notably educational level, for which causality appears likely. Consideration of this diversity and variability, its common occurrence in dyads and triads, and its impact on health outcomes according to age and gender may contribute to efficient surveillance and support the identification of prevention strategies targeting middle-aged men and women.

Neighbourhood socio-economic vulnerability and access to COVID-19 healthcare during the first two waves of the pandemic in Geneva, Switzerland: A gender perspective

BACKGROUND

Neighbourhood socio-economic inequities have been shown to affect COVID-19 incidence and mortality, as well as access to tests. This article aimed to study how associations of inequities and COVID-19 outcomes varied between the first two pandemic waves from a gender perspective.

METHODS

We performed an ecological study based on the COVID-19 database of Geneva between Feb 26, 2020, and June 1, 2021. Outcomes were the number of tests per person, the incidence of COVID-19 cases, the incidence of COVID-19 deaths, the positivity rate, and the delay between symptoms and test. Outcomes were described by neighbourhood socio-economic levels and stratified by gender and epidemic waves (first wave, second wave), adjusting for the proportion of inhabitants older than 65 years.

FINDINGS

Low neighbourhood socio-economic levels were associated with a lower number of tests per person (incidence rate ratio [IRR] of 0.88, 0.85 and 0.83 for low, moderate, and highly vulnerable neighbourhood respectively), a higher incidence of COVID-19 cases and of COVID-19 deaths (IRR 2.3 for slightly vulnerable, 1.9 for highly vulnerable). The association between socio-economic inequities and incidence of COVID-19 deaths was mainly present during the first wave of the pandemic, and was stronger amongst women. The increase in COVID-19 cases amongst vulnerable populations appeared mainly during the second wave, and originated from a lower access to tests for men, and a higher number of COVID-19 cases for women.

INTERPRETATION

The COVID-19 pandemic affected people differently depending on their socio-economic level. Because of their employment and higher prevalence of COVID-19 risk factors, people living in neighbourhoods of lower socio-economic levels, especially women, were more exposed to COVID-19 consequences.

FUNDING

This research was supported by the research project SELFISH, financed by the Swiss National Science Foundation, grant number 51NF40-160590 (LIVES centre international research project call).

Household Tenure and Its Associations with Multiple Long-Term Conditions amongst Working-Age Adults in East London: A Cross-Sectional Analysis Using Linked Primary Care and Local Government Records

Multiple long-term conditions (MLTCs) are influenced in extent and nature by social determinants of health. Few studies have explored associations between household tenure and different definitions of MLTCs. This study aimed to examine associations between household tenure and MLTCs amongst working-age adults (16 to 64 years old, inclusive). This cross-sectional study used the 2019−2020 wave of an innovative dataset that links administrative data across health and local government for residents of a deprived borough in East London. Three definitions of MLTCs were operationalised based on a list of 38 conditions. Multilevel logistic regression models were built for each outcome and adjusted for a range of health and sociodemographic factors. Compared to working-age owner-occupiers, odds of basic MLTCs were 36% higher for social housing tenants and 19% lower for private renters (OR 1.36; 95% CI 1.30−1.42; p < 0.001 and OR 0.81, 95% CI 0.77−0.84, p < 0.001, respectively). Results were consistent across different definitions of MLTCs, although associations were stronger for social housing tenants with physical-mental MLTCs. This study finds strong evidence that household tenure is associated with MLTCs, emphasising the importance of understanding household-level determinants of health. Resources to prevent and tackle MLTCs among working-age adults could be differentially targeted by tenure type.

Prevalence, factors and inequalities in chronic disease multimorbidity among older adults in India: analysis of cross-sectional data from the nationally representative Longitudinal Aging Study in India (LASI)

OBJECTIVE

This study examines the prevalence, patterns and factors of chronic disease-related multimorbidity. Also, this study examines the inequality in the prevalence of multimorbidity among older adults in India.

DESIGN

Cross-sectional study; large nationally representative survey data.

SETTING AND PARTICIPANTS

We have used the first wave of a Longitudinal Ageing Study in India conducted in 2017-2018 across all the 35 states (excluded Sikkim) and union territories in India. This study used information from 31 373 older people aged 60+years in India.

PRIMARY AND SECONDARY OUTCOME MEASURES

The outcome variable for this study is multimorbidity. The study used multinomial logistic regression to examine the risk factors for multimorbidity among older adults. To measure the inequality in multimorbidity, the slope of index inequality and relative index of inequality have been used to understand the ranked-based inequality.

RESULTS

Almost one-fourth (24.1%) reported multimorbidity. The relative risk ratio (RRR) of multimorbidity (RRR=2.12; 95% CI=1.49 to 3.04) was higher among higher educated older adults than uneducated older adults. Furthermore, the RRR of multimorbidity (RRR=2.35; 95% CI=2.02 to 2.74) was higher among urban older adults than their rural counterparts. Older adults in the richest wealth quintile were more likely to report multimorbidities (RRR=2.86; 95% CI=2.29 to 3.55) than the poorest older adults. Good self-rated health and no activities of daily living disability were associated with a lower risk of multimorbidities.

CONCLUSIONS

This study contributes to the comprehensive knowledge of the prevalence, factors and inequality of the chronic disease-related multimorbidity among older adults in India. Considering India's ageing population and high prevalence of multimorbidity, the older adults must be preferred in disease prevention and health programmes, however, without compromising other subpopulations in the country. There is a need to develop geriatric healthcare services in India. Additionally, there is a need to disseminate awareness and management of multimorbidity among urban and highly educated older adults.

Primary care and cancer: an analysis of the impact and inequalities of the COVID-19 pandemic on patient pathways

OBJECTIVES

We explore the routes to cancer diagnosis to further undertanding of the inequality in the reduction in detection of new cancers since the start of the pandemic. We use different data sets to assess stages in the cancer pathway: primary care data for primary care consultations, routine and urgent referrals and published analysis of cancer registry data for appointments and first treatments.

SETTING

Primary and cancer care.

PARTICIPANTS

In this study we combine multiple data sets to perform a population-based cohort study on different areas of the cancer pathway. For primary care analysis, we use a random sample of 5 00 000 patients from the Clinical Practice Research Datalink. Postreferral we perform a secondary data analysis on the Cancer Wait Times data and the National Cancer Registry Analysis Service COVID-19 data equity pack.

OUTCOME MEASURES

Primary care: consultation, urgent cancer referral and routine referral rates, then appointments following an urgent cancer referral, and first treatments for new cancer, for all and by quintile of patient's local area index of multiple deprivation.

RESULTS

Primary care contacts and urgent cancer referrals in England fell by 11.6% (95% CI 11.4% to 11.7%) and 20.2% (95% CI 18.1% to 22.3%) respectively between the start of the first non-pharmaceutical intervention in March 2020 and the end of January 2021, while routine referrals had not recovered to prepandemic levels. Reductions in first treatments for newly diagnosed cancers are down 16.3% (95% CI 15.9% to 16.6%). The reduction in the number of 2-week wait referrals and first treatments for all cancer has been largest for those living in poorer areas, despite having a smaller reduction in primary care contact.

CONCLUSIONS

Our results further evidence the strain on primary care and the presence of the inverse care law, and the dire need to address the inequalities so sharply brought into focus by the pandemic. We need to address the disconnect between the importance we place on the role of primary care and the resources we devote to it.

Inequalities in the progress of multiple chronic conditions: A systematic review of longitudinal studies

The objective of this review is to assess the impact of socioeconomic factors on the progress of multiple chronic health conditions (MCC) in Adults. Two independent investigators searched three databases (MEDLINE, EMBASE and LILACS) up to August 2021 to identify longitudinal studies on inequalities in progress of MCC. Grey literature was searched using Open Grey and Google Scholar. Inclusion criteria were retrospective and prospective longitudinal studies; adult population; assessed socioeconomic inequalities in progress of MCC. Quality of included studies and risk of bias were assessed using the Newcastle Ottawa Quality Assessment Scale for longitudinal studies. Nine longitudinal studies reporting socioeconomic inequalities in progress of MCC were included. Two of the studies had poor quality. Studies varied in terms of follow-up time, sample size, included chronic conditions and socioeconomic indicators. Due to high heterogeneity meta-analysis was not possible. The studies showed positive association between lower education (five studies), lower income and wealth (two studies), area deprivation (one study), lower job categories (two studies) and belonging to ethnic minority (two study) and progress of MCC. The review demonstrated socioeconomic inequality in progress of multiple chronic conditions.

trial registratiom: The review protocol was registered in the International Prospective Register of Systematic Reviews (CRD42021229564).

Theoretical explanations for socioeconomic inequalities in multimorbidity: a scoping review

OBJECTIVE

To document socioepidemiological theories used to explain the relationship between socioeconomic disadvantage and multimorbidity.

DESIGN

Scoping review.

METHODS

A search strategy was developed and then applied to multiple electronic databases including Medline, Embase, PsychInfo, Web of Science, Scielo, Applied Social Sciences, ERIC, Humanities Index and Sociological Abstracts. After the selection of studies, data were extracted using a data charting plan. The last search was performed on the 28 September 2021. Extracted data included: study design, country, population subgroups, measures of socioeconomic inequality, assessment of multimorbidity and conclusion on the association between socioeconomic variables and multimorbidity. Included studies were further assessed on their use of theory, type of theories used and context of application. Finally, we conducted a meta-narrative synthesis to summarise the results.

RESULTS

A total of 64 studies were included in the review. Of these, 33 papers included theories as explanations for the association between socioeconomic position and multimorbidity. Within this group, 16 explicitly stated those theories and five tested at least one theory. Behavioural theories (health behaviours) were the most frequently used, followed by materialist (access to health resources) and psychosocial (stress pathways) theories. Most studies used theories as post hoc explanations for their findings or for study rationale. Supportive evidence was found for the role of material, behavioural and life course theories in explaining the relationship between social inequalities and multimorbidity.

CONCLUSION

Given the widely reported social inequalities in multimorbidity and its increasing public health burden, there is a critical gap in evidence on pathways from socioeconomic disadvantage to multimorbidity. Generating evidence of these pathways will guide the development of intervention and public policies to prevent multimorbidity among people living in social disadvantage. Material, behavioural and life course pathways can be targeted to reduce the negative effect of low socioeconomic position on multimorbidity.

The association between educational level and multimorbidity among adults in Southeast Asia: A systematic review

BACKGROUND

In Southeast Asia, the prevalence of multimorbidity is gradually increasing. This paper aimed to investigate the association between educational level and multimorbidity among over 15-years old adults in Southeast Asia.

METHODS

We conducted a systematic review of published observational studies. Studies were selected according to eligibility criteria of addressing definition and prevalence of multimorbidity and associations between level of education and multimorbidity in Southeast Asia. The Newcastle-Ottawa Scale (NOS) was used to measure the quality and risk of bias. The methodology has been published in PROSPERO with registered number ID: CRD42021259311.

RESULTS

Eighteen studies were included in the data synthesis. The results are presented using narrative synthesis due to the heterogeneity of differences in exposures, outcomes, and methodology. The prevalence of multimorbidity ranged from 1.7% to 72.6% among over 18 years-old adults and from 1.5% to 51.5% among older people (≥ 60 years). There were three association patterns linking between multimorbidity and education in these studies: (1) higher education reducing odds of multimorbidity, (2) higher education increasing odds of multimorbidity and (3) education having no association with multimorbidity. The association between educational attainment and multimorbidity also varies widely across countries. In Singapore, three cross-sectional studies showed that education had no association with multimorbidity among adults. However, in Indonesia, four cross-sectional studies found higher educated persons to have higher odds of multimorbidity among over 40-years-old persons.

CONCLUSIONS

Published studies have shown inconsistent associations between education and multimorbidity because of different national contexts and the lack of relevant research in the region concerned. Enhancing objective data collection such as physical examinations would be necessary for studies of the connection between multimorbidity and education. It can be hypothesised that more empirical research would reveal that a sound educational system can help people prevent multimorbidity.

What matters to people with multiple long-term conditions and their carers?

BACKGROUND

The number of people living with multiple long-term conditions is increasing worldwide. This presents challenges for health and care systems, which must adapt to meet the needs of this population. This study drew on existing data to understand what matters to people living with multiple long-term conditions and identify priorities for future research.

METHODS

Two studies were conducted. (1) A secondary thematic analysis of interview, survey and workshop data collected from the 2017 James Lind Alliance Priority Setting Partnership for Older People with Multiple Conditions, and patient and public involvement workshops; (2) a review of ongoing research and published research priorities, relating to older people (80+) living with multiple long-term conditions.

FINDINGS

Older people with multiple long-term conditions identified a number of key concerns: access to care, support for both the patient and their carer, physical and mental health and well-being and identifying opportunities for early prevention. The review identified no published research priorities or ongoing research focusing specifically on populations aged over 80 years with multiple long-term conditions.

CONCLUSION

Older people living with multiple long-term conditions experience care that is inadequate for their needs. A holistic approach to care that extends beyond treating single conditions will ensure wide-ranging needs are met. As multimorbidity rises worldwide, this is a critical message for practitioners across health and care settings. We also recommend key areas that should be given greater focus in future research and policy to inform effective and meaningful forms of support for people living with multiple long-term conditions.

Pre-COVID-19 Social Determinants of Health Among Mexican Migrants in Los Angeles and New York City and Their Increased Vulnerability to Unfavorable Health Outcomes During the COVID-19 Pandemic

COVID-19 has disproportionally affected underrepresented minorities (URM) and low-income immigrants in the United States. The aim of the study is to examine the underlying vulnerabilities of Mexican immigrants in New York City (NYC) and Los Angeles (LA), its correspondence with area-level COVID-19 morbidity and mortality, and to document the role of trusted and culturally sensitive services offered during the pandemic through the Ventanillas de Salud (i.e. VDS, Health Windows) program. The study uses a mixed-methods approach including a cross-sectional survey of Mexican immigrants in LA and NYC collected in the Mexican Consulates at the onset of the pandemic, complemented with a georeferencing analysis and key informant interviews. Data suggested an increased vulnerability to COVID-19 given participants reported health status, health care profile and place of residence, which coincided with the georeferencing analysis. The key informant interviews confirmed the vulnerability of this population and the supporting role of VDS in helping immigrants navigate health systems and disseminate health information. Mexican immigrants had an increased vulnerability to COVID-19 at the individual, geographic and systemic levels. Trusted and culturally sensitive services are needed to overcome some of the barriers and risk factors that increase the vulnerability of URM and immigrant populations to COVID-19.

Geographic Factors Associated with Poorer Outcomes in Patients Diagnosed with COVID-19 in Primary Health Care

Background: The prognosis of older age COVID-19 patients with comorbidities is associated with a more severe course and higher fatality rates but no analysis has yet included factors related to the geographical area/municipality in which the affected patients live, so the objective of this study was to analyse the prognosis of patients with COVID-19 in terms of sex, age, comorbidities, and geographic variables. Methods: A retrospective cohort of 6286 patients diagnosed with COVID-19 was analysed, considering demographic data, previous comorbidities and geographic variables. The main study variables were hospital admission, intensive care unit (ICU) admission and death due to worsening symptoms; and the secondary variables were sex, age, comorbidities and geographic variables (size of the area of residence, distance to the hospital and the driving time to the hospital). A comparison analysis and a multivariate Cox model were performed. Results: The multivariate Cox model showed that women had a better prognosis in any type of analysed prognosis. Most of the comorbidities studied were related to a poorer prognosis except for dementia, which is related to lower admissions and higher mortality. Suburban areas were associated with greater mortality and with less hospital or ICU admission. Distance to the hospital was also associated with hospital admission. Conclusions: Factors such as type of municipality and distance to hospital act as social health determinants. This fact must be taken account in order to stablish specifics prevention measures and treatment protocols.

Mental Illness Inequalities by Multimorbidity, Use of Health Resources and Socio-Economic Status in an Aging Society

BACKGROUND

Mental illness, multi-morbidity, and socio-economic inequalities are some of the main challenges for the public health system nowadays, and are further aggravated by the process of population aging. Therefore, it is widely accepted that health systems need to focus their strategies for confronting such concerns. With guaranteed access to health care services under universal coverage in many health systems, it is expected that all services be provided equally to patients with the same level of need.

METHODS

In this paper, we explore the existence of inequalities in the access to services of patients with mental illness taking into account whether they are multimorbid patients, their socioeconomic status, and their age. We take advantage of a one-year (2010-2011) database on individual healthcare utilization and expenditures for the total population (N = 2,262,698) of the Basque Country.

RESULTS

More comorbidity leads to greater inequality in prevalence, being the poor sicker, although with age, this inequality decreases. All health services are more oriented towards greater utilization of the poor and sicker, particularly in the case of visits to specialists and emergency care.

CONCLUSIONS

Mental health inequalities in prevalence have been identified as being disproportionally concentrated in the least affluent areas of the Basque Country. However, inequalities in the utilization of publicly-provided health services present a pro-poor orientation. As this region has adopted a system-wide transformation towards integrated care, its mental health delivery model offers excellent potential for international comparisons and benchlearning.