In this issue: Challenges of managing multimorbidity

Guiding Post-Hospital Recovery by 'What Matters:' Implementation of Patient Priorities Identification in a VA Community Living Center

BACKGROUND

Patient priorities care (PPC) is an effective age-friendly health systems (AFHS) approach to aligning care with goals derived from 'what matters'. The purpose of this quality improvement program was to evaluate the fidelity and feasibility of the health priorities identification (HPI) process in VA Community Living Centers (CLC).

METHODS

PPC experts worked with local CLC staff to guide the integration of HPI into the CLC and utilized a Plan-Do-Study-Act (PDSA) model for this quality improvement project. PPC experts reviewed health priorities identification (HPI) encounters and interdisciplinary team (IDT) meetings for fidelity to the HPI process of PPC. Qualitative interviews with local CLC staff determined the appropriateness of the health priorities identification process in the CLC.

RESULTS

Over 8 months, nine facilitators completed twenty HPI encounters. Development of a Patient Health Priorities note template, staff education and PPC facilitator training improved fidelity and documentation of HPI encounters in the electronic health record. Facilitator interviews suggested that PPC is appropriate in this setting, not burdensome to staff and fostered a person-centered approach to AFHS.

CONCLUSIONS

The HPI process is an acceptable and feasible approach to ask the 'what matters' component of AFHS in a CLC setting.

Effect of Family Practice Contract Services on the Perceived Quality of Primary Care among Patients with Multimorbidity: A Cross-Sectional Study in Guangdong, China

Family practice contract services, an important primary-care reform policy for improving primary healthcare quality in China, incorporate patients with multiple chronic conditions into the priority coverage groups and focus on their management. This study aims to explore the family practice contract services' effectiveness in improving the quality of primary care experienced by this population. A cross-sectional study using a three-stage sampling was conducted from January to March 2019 in Guangdong, China. A multivariable linear regression, including interaction terms, was applied to examine the associations between the contract services and primary care quality among people with different chronic conditions. The process quality of primary care was measured in six dimensions using the validated assessment survey of primary care (ASPC) scale. People with contract services scored higher in terms of quality of primary care than those without contract services. Contract services moderated the association between chronic condition status and primary care quality. Significantly positive interactions were observed in the patient-centred care dimension and negative interactions were reflected in the accessibility dimension. Our findings suggest that family practice contract services play a crucial role in improving patient-perceived primary care quality and provide emerging evidence that patients with multimorbidity tend to benefit more from the services, especially in patient-centred care.

Self-management strategies and comorbidities in chronic disease patients: associations with quality of life and depression

Self-management strategies are essential for improving prognosis in chronic illnesses. This study aimed to investigate the association between comorbidity and self-management strategies. A total of 700 patients with one or more chronic diseases including diabetes, dyslipidemia, hypertension, osteoporosis, chronic lung disease, chronic kidney disease and arthritis were enrolled. A questionnaire including the Smart Management Strategy for Health Assessment Tool Short Form (SAT), the Short Form-12, the McGill Quality of Life questionnaire, and the Patient Health Questionnaire-9 was administered to participants. The trend of each SAT according to number of comorbidities was evaluated, and the difference in quality of life and depression according to self-management strategies was examined in the model classified by the number of diseases. Self-management strategy scores tended to decrease as the number of comorbidities increased from one to four (p-value: 0.001 to 0.008). Regardless of the number of comorbidities, the MQOL score was higher in the good self-management strategy group (p: <0.001 to 0.016). The prevalence of mild depression was higher in patients with low self-management strategy, but the differences were not significant. Based on these findings, self-management strategies should be evaluated multidimensionally, and patients should be encouraged to develop effective self-management strategies to manage multiple chronic diseases.

Natural Language Processing Accurately Measures Adherence to Best Practice Guidelines for Palliative Care in Trauma

CONTEXT

The Trauma Quality Improvement Program Best Practice Guidelines recommend palliative care (PC) concurrent with restorative treatment for patients with life-threatening injuries. Measuring PC delivery is challenging: administrative data are nonspecific, and manual review is time intensive.

OBJECTIVES

To identify PC delivery to patients with life-threatening trauma and compare the performance of natural language processing (NLP), a form of computer-assisted data abstraction, to administrative coding and gold standard manual review.

METHODS

Patients 18 years and older admitted with life-threatening trauma were identified from two Level I trauma centers (July 2016-June 2017). Four PC process measures were examined during the trauma admission: code status clarification, goals-of-care discussion, PC consult, and hospice assessment. The performance of NLP and administrative coding were compared with manual review. Multivariable regression was used to determine patient and admission factors associated with PC delivery.

RESULTS

There were 76,791 notes associated with 2093 admissions. NLP identified PC delivery in 33% of admissions compared with 8% using administrative coding. Using NLP, code status clarification was most commonly documented (27%), followed by goals-of-care discussion (18%), PC consult (4%), and hospice assessment (4%). Compared with manual review, NLP performed more than 50 times faster and had a sensitivity of 93%, a specificity of 96%, and an accuracy of 95%. Administrative coding had a sensitivity of 21%, a specificity of 92%, and an accuracy of 68%. Factors associated with PC delivery included older age, increased comorbidities, and longer intensive care unit stay.

CONCLUSION

NLP performs with similar accuracy with manual review but with improved efficiency. NLP has the potential to accurately identify PC delivery and benchmark performance of best practice guidelines.

Investigation of multimorbidity and prevalent disease combinations in older Irish adults using network analysis and association rules

Multimorbidity (the presence of multiple medical conditions) is well known to increase with age. People with multimorbidities often have higher physical and functional decline as well as increased mortality. Despite growing evidence that integrated and collaborative care improves many undesirable outcomes of multimorbidity, the majority of health systems are based around treating individual diseases. A pattern analysis of comorbidities using network graphs and a novel use of association rules was conducted to investigate disease associations on 6101 Irish adults aged 50+. The complex network of morbidities and differences in the prevalence and interactions of these morbidities by sex was also assessed. Gender specific differences in disease prevalence was found for 22/31 medical conditions included in this study. Females had a more complex network of disease associations than males with strong associations found between arthritis, osteoporosis and thyroid issues among others. To assess the strength of these associations we provide probabilities of being diagnosed with a comorbid condition given the presence of an index morbidity for 639 pairwise combinations. This information can be used to guide clinicians in deciding which comorbidities should be incorporated into comprehensive assessments in addition to anticipating likely future morbidities and thus developing prevention strategies.

Overweight: A Protective Factor against Comorbidity in the Elderly

The aim of this study was to investigate the relationship between body mass index (BMI) categories and comorbidity in 9067 patients (age range 18‒94 years) who underwent upper digestive endoscopy in Northern Sardinia, Italy. The majority of participants (62.2%) had a BMI under 25 kg/m², overweight was detected in 30.4%, and obesity (BMI ≥ 30 kg/m²) in 7.4% of patients. The most frequent illness recorded was hypertension followed by cardiovascular and liver disease. The multivariate analysis, after adjusting for sex, residence, marital status, smoking habits, occupation and hospitalization detected an association between comorbidity and aging that was statistically significant and progressive. Among patients younger than 60 years (n = 5612) the comorbidity risk was higher for BMI ranging 27.5‒29.9 kg/m² compared with BMI 25.0‒27.4 kg/m² (RR = 1.38; 95% CI 1.27‒1.50 vs. RR = 0.86; 95% CI 0.81‒0.90). In patients older than 60 years (n= 3455) the risk was lower for a BMI in the range 27.5–29.9 kg/m² compared with a BMI in the range 25.0–27.4 kg/m² (RR = 1.11; 95% CI 1.05‒1.18 vs. RR = 1.28; 95% CI 1.21‒1.35). These results suggest that being moderately overweight is a marker of a healthy aging process and might protect, at least in part, against comorbidity. However, further research is needed to better understand this unexpected finding.

Fused comparative intervention scoring for heterogeneity of longitudinal intervention effects

With the growing cost of health care in the United States, the need to improve efficiency and efficacy has become increasingly urgent. There has been a keen interest in developing interventions to effectively coordinate the typically fragmented care of patients with many comorbidities. Evaluation of such interventions is often challenging given their long-term nature and their differential effectiveness among different patients. Furthermore, care coordination interventions are often highly resource-intensive. Hence there is pressing need to identify which patients would benefit the most from a care coordination program. In this work we introduce a subgroup identification procedure for long-term interventions whose effects are expected to change smoothly over time. We allow differential effects of an intervention to vary over time and encourage these effects to be more similar for closer time points by utilizing a fused lasso penalty. Our approach allows for flexible modeling of temporally changing intervention effects while also borrowing strength in estimation over time. We utilize our approach to construct a personalized enrollment decision rule for a complex case management intervention in a large health system and demonstrate that the enrollment decision rule results in improvement in health outcomes and care costs. The proposed methodology could have broad usage for the analysis of different types of long-term interventions or treatments including other interventions commonly implemented in health systems.

Comorbidity and healthcare use for individuals with CVD in the Ireland: a cross-sectional, population-based study

OBJECTIVE

This study explores the factors associated with health service use for individuals with cardiovascular disease (CVD) and comorbidity in the Ireland.

DESIGN

Population-based cross-sectional survey.

SETTING

Nationally representative health and health service use survey from the 2010 Quarterly National Household Survey was analysed.

PRIMARY OUTCOME MEASURES

Four outcome variables were examined: no CVD, CVD only, CVD with CVD-related comorbidities and CVD with non-CVD-related comorbidity.

RESULTS

Of the 791 individuals reporting doctor-diagnosed CVD, 77% had a second morbidity. Using type of healthcare coverage as a proxy for socioeconomic status, both CVD-related and non CVD-related comorbidity increases the use of health service usage substantially for individuals with CVD, particularly general practitioner services (8.47, CI 4.49 to 15.96 and 5.20, CI 2.10 to 12.84) and inpatient public hospital care (3.64, CI 2.93 to 4.51 and 3.00, CI 2.11 to 4.26).

CONCLUSION

This study indicated that even when demographic and socioeconomic factors are controlled for, comorbidity significantly increases the risk of accessing health services for individuals with CVD.

Multimorbidity Burden and Adverse Outcomes in a Community-Based Cohort of Adults with Heart Failure

OBJECTIVES

To assess multimorbidity burden and its association with clinical outcomes in adults with heart failure (HF) according to sex, age, and HF type.

DESIGN

Retrospective cohort study.

SETTING

Five healthcare delivery systems across the United States.

PARTICIPANTS

Adults with HF (N=114,553).

MEASUREMENTS

We characterized participants with respect to the presence of 26 chronic conditions categorized into quartiles based on overall burden of comorbidity (<5, 5-6, 7-8, ≥9). Outcomes included all-cause death and hospitalization for HF or any cause. Multivariable Cox regression was used to evaluate the adjusted association between categorized burden of multimorbidity burden and outcomes.

RESULTS

Individuals with more morbidities were more likely to die than those with fewer then 5 morbidities (5-6 morbidities: adjusted hazard ratio (aHR)=1.27 (95% confidence interval (CI)=1.24-1.31; 7-8 morbidities: aHR=1.52, 95% CI=1.48-1.57; ≥9 morbidities: aHR=1.92, 95% CI=1.86-1.99). There was a graded, higher adjusted rate of any-cause hospitalization associated with 5 or 6 (aHR=1.28, 95% CI=1.25-1.30), 7 or 8 (aHR=1.47, 95% CI=1.44-1.50), or 9 or more (aHR=1.77, 95% CI=1.73-1.82) morbidities (vs <5). Similar findings were observed for HF-specific hospitalization in those with 5 or 6 (aHR=1.22, 95% CI=1.19-1.26), 7 or 8 (aHR=1.39, 95% CI=1.34-1.44), or 9 or more (aHR 1.68, 95% CI=1.61-1.74) morbidities (vs <5). Consistent findings were seen according to sex, age group, and HF type (preserved, reduced, borderline HF), in the association between categorical burden of multimorbidity and outcomes especially prominent in individuals younger than 65.

CONCLUSION

After adjustment, higher levels of multimorbidity predicted worse HF outcomes and may be an important consideration in strategies to improve clinical and person-centered outcomes. J Am Geriatr Soc 66:2305-2313, 2018.

Perspectives of Patients, Clinicians, and Health System Leaders on Changes Needed to Improve the Health Care and Outcomes of Older Adults With Multiple Chronic Conditions

OBJECTIVE

To ascertain perspectives of multiple stakeholders on contributors to inappropriate care for older adults with multiple chronic conditions.

METHOD

Perspectives of 36 purposively sampled patients, clinicians, health systems, and payers were elicited. Data analysis followed a constant comparative method.

RESULTS

Structural factors triggering burden and fragmentation include disease-based quality metrics and need to interact with multiple clinicians. The key cultural barrier identified is the assumption that "physicians know best." Inappropriate decision making may result from inattention to trade-offs and adherence to multiple disease guidelines. Stakeholders recommended changes in culture, structure, and decision making. Care options and quality metrics should reflect a focus on patients' priorities. Clinician-patient partnerships should reflect patients knowing their health goals and clinicians knowing how to achieve them. Access to specialty expertise should not require visits.

DISCUSSION

Stakeholders' recommendations suggest health care redesigns that incorporate patients' health priorities into care decisions and realign relationships across patients and clinicians.

The burden of cardiovascular morbidity in a European Mediterranean population with multimorbidity: a cross-sectional study

BACKGROUND

Cardiovascular diseases are highly represented in multimorbidity patterns. Nevertheless, few studies have analysed the burden of these diseases in the population with multimorbidity. The objective of this study was to identify and describe the cardiovascular diseases among the patients with multimorbidity.

METHODS

We designed a cross-sectional study in patients ≥19 years old assigned to 251 primary health care centres in Catalonia, Spain. The main outcome was cardiovascular morbidity burden, defined as the presence of one or more of 24 chronic cardiovascular diseases in multimorbid patients (≥2 chronic conditions). Two groups were defined, with and without multimorbidity; the multimorbidity group was further divided into cardiovascular and non-cardiovascular subgroups. The secondary outcomes were: modifiable major cardiovascular risk factors (smoking, hypertension, hypercholesterolaemia, diabetes) and cardiovascular risk score (REGICOR, Registre Gironí del Cor). Other variables analysed were: sex, age (19-24, 25-44, 45-64, 65-79, and 80+ years), number of chronic diseases, urban setting, active toxic habits (smoking and alcohol), physical parameters and laboratory tests.

RESULTS

A total of 1,749,710 individuals were included (mean age, 47.4 years [SD: 17.8]; 50.7 % women), of which nearly half (46.8 %) had multimorbidity (95 % CI: 46.9-47.1). In patients with multimorbidity,, the cardiovascular burden was 54.1 % of morbidity (95 % CI: 54.0-54.2) and the four most prevalent cardiovascular diseases were uncomplicated hypertension (75.3 %), varicose veins of leg (20.6 %), "other" heart disease (10.5 %) and atrial fibrillation/flutter (6.7 %). In the cardiovascular morbidity subgroup, 38.2 % had more than one cardiovascular disease. The most prevalent duet and triplet combinations were uncomplicated hypertension & lipid disorder (38.8 %) and uncomplicated hypertension & lipid disorder & non-insulin dependent diabetes (11.3 %), respectively. By age groups, the same duet was the most prevalent in patients aged 45-80 years and in men aged 25-44 years. In women aged 19-44, varicose veins of leg & anxiety disorder/anxiety was the most prevalent; in men aged 19-24, it was uncomplicated hypertension & obesity. Patients with multimorbidity showed a higher cardiovascular risk profile than the non-multimorbidity group.

CONCLUSIONS

More than 50 % percent of patients with multimorbidity had cardiovascular diseases, the most frequent being hypertension. The presence of cardiovascular risk factors and the cardiovascular risk profile were higher in the multimorbidity group than the non-multimorbidity group. Hypertension, diabetes and dyslipidaemia constituted the most prevalent multimorbidity pattern.

Type of Multimorbidity and Patient-Doctor Communication and Trust among Elderly Medicare Beneficiaries

Background. Effective communication and high trust with doctor are important to reduce the burden of multimorbidity in the rapidly aging population of the US. However, the association of multimorbidity with patient-doctor communication and trust is unknown. Objective. We examined the relationship between multimorbidity and patient-doctor communication and trust among the elderly. Method. We used the Medicare Current Beneficiary Survey (2012) to analyze the association between multimorbidity and patient-doctor communication and trust with multivariable logistic regressions that controlled for patient's sociodemographic characteristics, health status, and satisfaction with care. Results. Most elderly beneficiaries reported effective communication (87.5-97.5%) and high trust (95.4-99.1%) with their doctors. The elderly with chronic physical and mental conditions were less likely than those with only physical conditions to report effective communication with their doctor (Adjusted Odds Ratio [95% Confidence Interval] = 0.80 [0.68, 0.96]). Multimorbidity did not have a significant association with patient-doctor trust. Conclusions. Elderly beneficiaries had high trust in their doctors, which was not affected by the presence of multimorbidity. Elderly individuals who had a mental condition in addition to physical conditions were more likely to report ineffective communication. Programs to improve patient-doctor communication with patients having cooccurring chronic physical and mental health conditions may be needed.

Association between body mass index and prevalence of multimorbidity: a cross-sectional study

OBJECTIVES

To explore the prevalence of multimorbidity in Serbia according to sex and body mass index (BMI) categories, and to examine the association between BMI and multimorbidity. In addition, this study examined the relationships between the main demographic and socio-economic characteristics of the population (age, settlement, education) and multimorbidity.

STUDY DESIGN

Secondary analysis of data from the 2013 Serbian National Health Survey.

METHODS

This study analyzed data from 13,103 participants aged ≥20 years with BMI data. The associations between BMI, age, education and multimorbidity were analyzed by multivariate logistic regression.

RESULTS

The overall prevalence of multimorbidity was higher than the overall prevalence of a single disease (26.9% vs 20.7%). The proportion of participants who reported two or more chronic diseases increased with each BMI category in both sexes, reaching the highest values in obese category III. Odds ratios (ORs) for the prevalence in all morbidity groups increased gradually with BMI category, and the highest OR values were found in obese category III. Males of obese category III were seven times more likely to have multimorbidity [OR 7.2, 95% confidence interval (CI) 4.2-12.6] than males of normal weight, whereas females of obese category III were nine and a half times more likely to have multimorbidity (OR 9.5, 95% CI 4.0-22.4) than females of normal weight. In the multivariable analysis, age (both sexes), low and middle level of education (males), and rural settlement and low level of education (females) were found to be predictors of multimorbidity.

CONCLUSIONS

This study found positive associations between obesity and multimorbidity and between overweight and multimorbidity. Recognizing these associations is of great importance from both clinical and public health perspectives because this could lead to an integrated approach for patients.

Medication Adherence and Blood Pressure Control Among Hypertensive Patients With Coexisting Long-Term Conditions in Primary Care Settings: A Cross-Sectional Analysis

Hypertension is a typical example of long-term disease posing formidable challenges to health care. One goal of antihypertensive therapy is to achieve optimal blood pressure (BP) control and reduce co-occurring chronic conditions (multimorbidity). This study aimed to assess the influence of multimorbidity on medication adherence, and to explore the association between poor BP control and multimorbidity, with implications for hypertension management.A cross-sectional design with multistage sampling was adopted to recruit Chinese hypertensive patients attending general out-patient clinics from 3 geographic regions in Hong Kong. A modified systemic sampling methodology with 1 patient as a sampling unit was used to recruit consecutive samples in each general out-patient clinic. Data were collected by face-to-face interviews using a standardized protocol. Poor BP control was defined as having systolic BP/diastolic BP ≥130/80 mm Hg for those with diabetes or chronic kidney disease; and ≥140/90 mm Hg for others. Medication adherence was assessed by a validated Chinese version of the Morisky Medication Adherence Scale. A simple unweighted enumeration was adopted to measure the combinations of coexisting long-term conditions. Binary logistic regression analysis was conducted with medication adherence and multimorbidity as outcome variables, respectively, after controlling for effects of patient-level covariates.The prevalence of multimorbidity was 47.4% (95% confidence interval [CI] 45.4%-49.4%) among a total of 2445 hypertensive patients. The proportion of subjects having 0, 1, and ≥2 additional long-term conditions was 52.6%, 29.1%, and 18.3%, respectively. The overall rate of poor adherence to medication was 46.6%, whereas the rate of suboptimal BP control was 48.7%. Albeit the influence of multimorbidity on medication adherence was not found to be statistically significant, patients with poorly controlled BP were more likely to have multimorbidity (adjusted odds ratio 2.07, 95% CI 1.70-2.53, P < 0.001). Diabetes was the most prevalent concomitant long-term condition among hypertensive patients with poor BP control (38.6%, 95% CI 35.8-41.4 vs 19.7%, 95% CI 17.5-21.9 for patients with good BP control, P < 0.001).Multimorbidity was common among hypertensive patients, and was associated with poor BP control. Subjects with coexisting diabetes, heart disease, or chronic kidney disorder should receive more clinical attention to achieve better clinical outcomes.

Association Between Body Mass index and Prevalence of Multimorbidity in Low-and Middle-income Countries: A Cross-Sectional Study

BACKGROUND

Chronic diseases are increasingly becoming a health burden in terms of both morbidity and mortality in low and middle-income countries (LMICs). The role of body mass index (BMI) especially overweight and obesity in the prevalence of multimorbidity, the occurrence of two or more chronic conditions, is understudied in LMICs where two thirds of the world's obese individuals reside. We estimated the association between BMI and prevalence of chronic non communicable disease multimorbidity in six LMICs.

METHODS

Cross-sectional data of total of 40,166 participants from China (n=13,970), India (10,915), Mexico (2,4 26), Russia (3,892), South Africa (4,000) and Ghana (4,971), aged 18 years and above included in the WHO Study on Global Ageing and adult health (SAGE), 2007-2010 were analyzed. Multimorbidity was measured as the simultaneous presence of two or more of the nine chronic conditions including angina pectoris, arthritis, asthma, chronic lung disease, diabetes mellitus, hypertension, stroke, depression, and vision impairment. Multivariable logistic regression models were fitted to test for associations between overweight/obesity and prevalence of non communicable multimorbidity after adjusting for age, sex, rural/urban residence, education, marital status, occupation, household wealth, tobacco smoking, alcohol drinking, fruits and vegetable intake and health insurance status. Data were analyzed country wise as well as pooled together to give overall LMIC estimates.

RESULTS

The mean BMI was 24.4 [±7.3SD] in the pooled countries, being as low as 20.8 [±8.0 SD] in India to 23.4 [±6.3 SD] in Ghana, 23.9 [±4.9 SD] in China, 28.4 [±5.4 SD] in Mexico, 28.6 [±6.3 SD] in Russia, to as high as 30.5 [±12.0 SD] in South Africa. The prevalence of overweight was 13% and obesity was 24% in the pooled sample. The prevalence of non communicable disease multimorbidity was 23% in the pooled sample of six countries-the highest being in Russia (50%), followed by Mexico (27%), India (24%), Ghana (23%), South Africa (32%) and China (22%). The prevalence of multimorbidity was 37% among obese population and 27% among overweight population in the pooled sample-highest prevalence was in Russia (59% among obese; 45% among overweight) and lowest in Ghana (28% among obese; 23% among overweight). Being obese (OR:5.78;95%CI:3.55-9.40;p<0.0001) was associated with significantly higher likelihood of having multimorbidity as compared to normal weight category in the pooled sample. The likelihood of multimorbidity among obese were almost ten times higher in Russia (OR:9.90;95%CI:3.90-25.17;p=<0.0001), seven times higher in China (OR:7.06;95%CI:2.47-20.21;p=0.003), six times higher in Ghana (OR:5.61;95%CI:1.21-26.02;p= 0.007) and five times higher in South Africa (OR:4.66;95%CI:2.16-10.08;p=0.005). Non-significant but positive association were also observed in case of India and Mexico. The likelihood of multimorbidity was more than two times higher among overweight population in India (OR:2.33;95%CI:1.35-4.02;p=0.003) and pooled countries (OR:1.47;95%CI:1.05-2.07;p=0.004) while non-significant but positive association were also observed in case of China, Russia, and Ghana.

CONCLUSIONS

The prevalence of non communicable disease multimorbidity in the LMICs is high, one and half times higher in obese than in normal weight individual. Obesity was independently associated with the occurrence of multimorbidity in the six LMICs. These findings may be vital for public health surveillance, prevention and management strategies for non communicable disease multimorbidity in the LMICs.

Patient Priority-Directed Decision Making and Care for Older Adults with Multiple Chronic Conditions

Older adults with multiple conditions receive care that is often fragmented, burdensome, and of unclear benefit. An advisory group of patients, caregivers, clinicians, health system engineers, health care system leaders, payers, and others identified three modifiable contributors to this fragmented, burdensome care: decision making and care focused on diseases, not patients; inadequate delineation of roles and responsibilities and accountability among clinicians; and lack of attention to what matters to patients and caregivers (ie, their health outcome goals and care preferences). The advisory group identified patient priority-directed care as a feasible, sustainable approach to addressing these modifiable factors.

Epidemiology of multimorbidity in China and implications for the healthcare system: cross-sectional survey among 162,464 community household residents in southern China

BACKGROUND

China, like other countries, is facing a growing burden of chronic disease but the prevalence of multimorbidity and implications for the healthcare system have been little researched. We examined the epidemiology of multimorbidity in southern China in a large representative sample. The effects of multimorbidity and other factors on usual source of healthcare were also examined.

METHODS

We conducted a large cross-sectional survey among approximately 5% (N = 162,464) of the resident population in three prefectures in Guangdong province, southern China in 2011. A multistage, stratified random sampling was adopted. The study population had many similar characteristics to the national census population. Interviewer-administered questionnaires were used to collect self-report data on demographics, socio-economics, lifestyles, healthcare use, and health characteristics from paper-based medical reports.

RESULTS

More than one in ten of the total study population (11.1%, 95% confidence interval (CI) 10.6 to 11.6) had two or more chronic conditions from a selection of 40 morbidities. The prevalence of multimorbidity increased with age (adjusted odds ratio (aOR) = 1.36, 95% CI 1.35 to 1.38 per five years). Female gender (aOR = 1.70, 95% CI 1.64 to 1.76), low education (aOR = 1.26, 95% CI 1.23 to 1.29), lack of medical insurance (aOR = 1.79, 95% CI 1.71 to 1.89), and unhealthy lifestyle behaviours were independent predictors of multimorbidity. Multimorbidity was associated with the regular use of secondary outpatient care in preference to primary care.

CONCLUSIONS

Multimorbidity is now common in China. The reported preferential use of secondary care over primary care by patients with multimorbidity has many major implications. There is an urgent need to further develop a strong and equitable primary care system.

The association between multimorbidity and poor adherence with cardiovascular medications

Multimorbidity, defined as the presence of two or more chronic conditions, leads to a substantial public health burden. This study evaluated its association with adherence with cardiovascular medications in a Chinese population. A proportional stratified sampling was adopted to draw a representative sample of residents living in Henan Province, China. Interviewer-administered surveys were conducted by trained researchers. The outcomes included the number of chronic medical conditions, adherence with long-term medications (MMAS-8), and depressive symptoms (CESD-20). Binary logistic regression analysis was conducted to evaluate if medication adherence was associated with the presence of multimorbidity. From a total of 3866 completed surveys, the proportion of subjects having 0, 1 and ≥2 chronic conditions was 62.6%, 23.8% and 13.5%, respectively. Among 27.6% who were taking chronic medications, 66.6% had poor medication adherence (MMAS-8 score≤6). From binary logistic regression analysis, subjects with poor medication adherence were significantly associated with multimorbidity (adjusted odds ratio [AOR]: 1.35, 95% C.I. 1.02-1.78, p=0.037). Other associated factors included older age (AOR=1.04, 95% C.I. 1.03-1.05, p<0.001), smoking (AOR=1.63, 95% C.I. 1.16-2.30, p=0.005), family history of hypertension (AOR=1.51, 95% C.I. 1.19-1.93, p=0.001), and fair to poor self-perceived health status (AOR=2.15, 95% C.I. 1.69-2.74, p<0.001). Using medication adherence as the outcome variable, multimorbidity was significantly associated with poor drug adherence (AOR=1.34, 95% C.I. 1.02-1.77, p=0.037). Multimorbidity was associated with poorer medication adherence. This implies the need for closer monitoring of the medication taking behavior among those with multiple chronic conditions.

Factors associated with multimorbidity and its link with poor blood pressure control among 223,286 hypertensive patients

Multimorbidity has become the norm worldwide as populations age. It remains, however, infrequently researched. This study evaluated factors associated with multimorbidity in a predominantly Chinese hypertensive population. We included all adult patients prescribed their first antihypertensive agents in the entire public sector in Hong Kong from a validated database. Multimorbidity was defined as having one or more medical conditions (cardiovascular diseases; respiratory diseases; diabetes or impaired fasting glucose; renal disease) in addition to hypertension. We studied the prevalence of multimorbidity and performed multinomial regression analyses to evaluate factors independently associated with multimorbidity. 223,286 hypertensive patients (average age of 59.9 years, SD 17.6) were included. The prevalence of having 0, 1 and ≥ 2 additional conditions was 59.6%, 32.8% and 7.5%, respectively. The most common conditions were cardiovascular disease (24.2%) and diabetes (23.0%), followed by respiratory disorders (14.6%) and renal disease (10.9%). Older age (>50 years), male sex, lower household income, receipt of social security allowance and suboptimal blood pressure control (>140 mmHg or >90 mmHg; >130 mmHg or >80 mmHg for diabetes patients; AOR = 3.38-4.49) were significantly associated with multimorbidity. There exists a synergistic effect among these variables as older (≥ 70 years), male patients receiving security allowance had substantially higher prevalence of multimorbidity (19.9% vs 7.5% among all patients). Multimorbidity is very common in hypertensive patients and its prevalence increased markedly with the presence of risk factors identified in this study. Hypertensive patients with multimorbidities should receive more meticulous clinical care as their blood pressure control tends to be poorer.

Prevalence, determinants and patterns of multimorbidity in primary care: a systematic review of observational studies

INTRODUCTION

Multimorbidity is a major concern in primary care. Nevertheless, evidence of prevalence and patterns of multimorbidity, and their determinants, are scarce. The aim of this study is to systematically review studies of the prevalence, patterns and determinants of multimorbidity in primary care.

METHODS

Systematic review of literature published between 1961 and 2013 and indexed in Ovid (CINAHL, PsychINFO, Medline and Embase) and Web of Knowledge. Studies were selected according to eligibility criteria of addressing prevalence, determinants, and patterns of multimorbidity and using a pretested proforma in primary care. The quality and risk of bias were assessed using STROBE criteria. Two researchers assessed the eligibility of studies for inclusion (Kappa= 0.86).

RESULTS

We identified 39 eligible publications describing studies that included a total of 70,057,611 patients in 12 countries. The number of health conditions analysed per study ranged from 5 to 335, with multimorbidity prevalence ranging from 12.9% to 95.1%. All studies observed a significant positive association between multimorbidity and age (odds ratio [OR], 1.26 to 227.46), and lower socioeconomic status (OR, 1.20 to 1.91). Positive associations with female gender and mental disorders were also observed. The most frequent patterns of multimorbidity included osteoarthritis together with cardiovascular and/or metabolic conditions.

CONCLUSIONS

Well-established determinants of multimorbidity include age, lower socioeconomic status and gender. The most prevalent conditions shape the patterns of multimorbidity. However, the limitations of the current evidence base means that further and better designed studies are needed to inform policy, research and clinical practice, with the goal of improving health-related quality of life for patients with multimorbidity. Standardization of the definition and assessment of multimorbidity is essential in order to better understand this phenomenon, and is a necessary immediate step.

Population targeting and durability of multimorbidity collaborative care management

OBJECTIVES

A patient-centered collaborative care program for depression and uncontrolled diabetes and/or coronary heart disease (CHD) demonstrated improved clinical outcomes relative to usual care. We report clinically stratified analyses of patient outcomes to inform the duration and targeting of care management services for complex patients with multimorbidity.

METHODS

A 12-month randomized controlled trial of a multimorbidity collaborative care program followed patients at 6, 12, 18, and 24 months for diabetes (glycated hemoglobin [A1C]), blood pressure (systolic; SBP), low-density lipoprotein (LDL) cholesterol, and depression (Symptoms Check List-20 score). Depressed patients with less favorable medical control (Patient Health Questionnaire-9 score > 10, A1C > 8.0 %, SBP > 140 mm Hg, and LDL cholesterol > 120 mg/dL) were compared with depressed patients with more favorable medical control to describe differential intervention benefits over time.

RESULTS

In contrast to patients with more favorable baseline control, patients with depression and unfavorable control of A1C, SBP, and LDL at baseline showed improved outcomes as early as the 6-month follow-up assessment. Clinical benefits in the intervention group were largely sustained over the 24-month follow-up, except for some deterioration of glycemic control in intervention patients and trends toward improvement among controls over time. Among patients with depression and more favorable medical control at baseline, there were minimal between-group differences in medical disease outcomes.

CONCLUSIONS

Clinical benefits of a multimorbidity collaborative care management program occurred early, and were only found among patients with poor control of baseline diabetes and CHD risk factors. Targeting may maximize reach and improve affordability of complex care management.

Managing patients with multimorbidity: systematic review of interventions in primary care and community settings

OBJECTIVE

To determine the effectiveness of interventions designed to improve outcomes in patients with multimorbidity in primary care and community settings.

DESIGN

Systematic review.

DATA SOURCES

Medline, Embase, CINAHL, CAB Health, Cochrane central register of controlled trials, the database of abstracts of reviews of effectiveness, and the Cochrane EPOC (effective practice and organisation of care) register (searches updated in April 2011).

ELIGIBILITY CRITERIA

Randomised controlled trials, controlled clinical trials, controlled before and after studies, and interrupted time series analyses reporting on interventions to improve outcomes for people with multimorbidity in primary care and community settings. Multimorbidity was defined as two or more chronic conditions in the same individual. Outcomes included any validated measure of physical or mental health and psychosocial status, including quality of life outcomes, wellbeing, and measures of disability or functional status. Also included were measures of patient and provider behaviour, including drug adherence, utilisation of health services, acceptability of services, and costs.

DATA SELECTION

Two reviewers independently assessed studies for eligibility, extracted data, and assessed study quality. As meta-analysis of results was not possible owing to heterogeneity in participants and interventions, a narrative synthesis of the results from the included studies was carried out.

RESULTS

10 studies examining a range of complex interventions totalling 3407 patients with multimorbidity were identified. All were randomised controlled trials with a low risk of bias. Two studies described interventions for patients with specific comorbidities. The remaining eight studies focused on multimorbidity, generally in older patients. Consideration of the impact of socioeconomic deprivation was minimal. All studies involved complex interventions with multiple components. In six of the 10 studies the predominant component was a change to the organisation of care delivery, usually through case management or enhanced multidisciplinary team work. In the remaining four studies, intervention components were predominantly patient oriented. Overall the results were mixed, with a trend towards improved prescribing and drug adherence. The results indicated that it is difficult to improve outcomes in this population but that interventions focusing on particular risk factors in comorbid conditions or functional difficulties in multimorbidity may be more effective. No economic analyses were included, although the improvements in prescribing and risk factor management in some studies could provide potentially important cost savings.

CONCLUSIONS

Evidence on the care of patients with multimorbidity is limited, despite the prevalence of multimorbidity and its impact on patients and healthcare systems. Interventions to date have had mixed effects, although are likely to be more effective if targeted at risk factors or specific functional difficulties. A need exists to clearly identify patients with multimorbidity and to develop cost effective and specifically targeted interventions that can improve health outcomes.