The European General Practice Research Network presents a comprehensive definition of multimorbidity in family medicine and long term care, following a systematic review of relevant literature

Complex multimorbidity in hemodialysis patients: Study in a metropolitan region in Brazil

The objective of this article was to analyze the factors associated with complex multimorbidity (CMM) among hemodialysis patients in a metropolitan region in southeastern Brazil. To this end, a cross-sectional epidemiological survey was carried out with 1,024 individuals in the year 2019. CMM data were collected through the application of a questionnaire to hemodialysis patients. The binary logistic regression model was used to estimate odds ratios (OR) and 95% confidence intervals (95%CI) between independent variables and CMM. The prevalence of CMM was 81% and the results indicated that: living in cities with a low rate of general mortality (OR = 0.395, 95%CI = 0.179-0.870), being aged between 18 and 29 (OR = 0.402, 95%CI = 0.196-0.825), having an elementary education (OR = 0.536, 95%CI = 0.290-0.966) and assessing health as good/very good (OR = 0.446, 95%CI = 0.301-0.661) are factors that reduced the chances of having CMM, whereas a longer period of hemodialysis (OR = 1.779 and 95%CI = 1.057-2.997) increased the chances of CMM. The findings show that characteristics of the social and individual context are associated with CMM in hemodialysis patients, signaling the need for public health policies that include monitoring the complex multimorbidity condition among individuals undergoing hemodialysis treatment.

Assessing the relationship between multimorbidity, NCD configurations, frailty phenotypes, and mortality risk in older adults

BACKGROUND

Older adults are increasingly susceptible to prolonged illness, multiple chronic diseases, and disabilities, which can lead to the coexistence of multimorbidity and frailty. Multimorbidity may result in various noncommunicable disease (NCD) patterns or configurations that could be associated with frailty and death. Mortality risk may vary depending on the presence of specific chronic diseases configurations or frailty.

METHODS

The aim was to examine the impact of NCD configurations on mortality risk among older adults with distinct frailty phenotypes. The population was analyzed from the Costa Rican Longevity and Healthy Aging Study Cohort (CRELES). A total of 2,662 adults aged 60 or older were included and followed for 5 years. Exploratory factor analysis and various clustering techniques were utilized to identify NCD configurations. The frequency of NCD accumulation was also assessed for a multimorbidity definition. Frailty phenotypes were set according to Fried et al. criteria. Kaplan‒Meier survival analyses, mortality rates, and Cox proportional hazards models were estimated.

RESULTS

Four different types of patterns were identified: 'Neuro-psychiatric', 'Metabolic', 'Cardiovascular', and 'Mixt' configurations. These configurations showed a higher mortality risk than the mere accumulation of NCDs [Cardiovascular HR:1.65 (1.07-2.57); 'Mixt' HR:1.49 (1.00-2.22); ≥3 NCDs HR:1.31 (1.09-1.58)]. Frailty exhibited a high and constant mortality risk, irrespective of the presence of any NCD configuration or multimorbidity definition. However, HRs decreased and lost statistical significance when phenotypes were considered in the Cox models [frailty + 'Cardiovascular' HR:1.56 (1.00-2.42); frailty + 'Mixt':1.42 (0.95-2.11); and frailty + ≥ 3 NCDs HR:1.23 (1.02-1.49)].

CONCLUSIONS

Frailty accompanying multimorbidity emerges as a more crucial indicator of mortality risk than multimorbidity alone. Therefore, studying NCD configurations is worthwhile as they may offer improved risk profiles for mortality as alternatives to straightforward counts.

Role of family medicine physicians in providing nutrition support to older patients admitted to orthopedics departments: a grounded theory approach

BACKGROUND

Care of older adults requires comprehensive management and control of systemic diseases, which can be effectively managed by family physicians. Complicated medical conditions in older patients admitted to orthopedic departments (orthopedic patients) necessitate interprofessional collaboration. Nutrition is one of the essential components of management involved in improving the systemic condition of older patients. Nutrition support teams play an important role in nutrition management and can be supported by family physicians. However, the role of family physicians in nutrition support teams is not well documented. This study aimed to investigate the role of family physicians in supporting nutrition management in orthopedic patients.

METHODS

This qualitative study was conducted between January and June 2023 using constructivist grounded theory methodology. Eight family medicine physicians, three orthopedic surgeons, two nurses, two pharmacists, four rehabilitation therapists, four nutritionists, and one laboratory technician working in Japanese rural hospitals participated in the research. Data collection was performed through ethnography and semi-structured interviews. The analysis was performed iteratively during the study.

RESULTS

Using a grounded theory approach, four theories were developed regarding family physicians' role in providing nutrition support to orthopedic patients: hierarchical and relational limitation, delay of onset and detection of the need for geriatric care in orthopedic patients, providing effective family medicine in hospitals, and comprehensive management through the nutrition support team.

CONCLUSIONS

The inclusion of family physicians in nutrition support teams can help with early detection of the rapid deterioration of orthopedic patients' conditions, and comprehensive management can be provided by nutrition support teams. In rural primary care settings, family physicians play a vital role in providing geriatric care in community hospitals in collaboration with specialists. Family medicine in hospitals should be investigated in other settings for better geriatric care and to drive mutual learning among healthcare professionals.

Effectiveness of an adaptive, multifaceted intervention to enhance care for patients with complex multimorbidity in general practice: protocol for a pragmatic cluster randomised controlled trial (the MM600 trial)

INTRODUCTION

Patients with complex multimorbidity face a high treatment burden and frequently have low quality of life. General practice is the key organisational setting in terms of offering people with complex multimorbidity integrated, longitudinal, patient-centred care. This protocol describes a pragmatic cluster randomised controlled trial to evaluate the effectiveness of an adaptive, multifaceted intervention in general practice for patients with complex multimorbidity.

METHODS AND ANALYSIS

In this study, 250 recruited general practices will be randomly assigned 1:1 to either the intervention or control group. The eligible population are adult patients with two or more chronic conditions, at least one contact with secondary care within the last year, taking at least five repeat prescription drugs, living independently, who experience significant problems with their life and health due to their multimorbidity. During 2023 and 2024, intervention practices are financially incentivised to provide an extended consultation based on a patient-centred framework to eligible patients. Control practices continue care as usual. The primary outcome is need-based quality of life. Outcomes will be evaluated using linear and logistic regression models, with clustering considered. The analysis will be performed as intention to treat. In addition, a process evaluation will be carried out and reported elsewhere.

ETHICS AND DISSEMINATION

The trial will be conducted in compliance with the protocol, the Helsinki Declaration in its most recent form and good clinical practice recommendations, as well as the regulation for informed consent. The study was submitted to the Danish Capital Region Ethical Committee (ref: H-22041229). As defined by Section 2 of the Danish Act on Research Ethics in Research Projects, this project does not constitute a health research project but is considered a quality improvement project that does not require formal ethical approval. All results from the study (whether positive, negative or inconclusive) will be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT05676541.

Challenges Faced by Medical Trainees in Outpatient Management Education in Acute Care Hospitals: A Thematic Analysis

Introduction As societies age globally, medical education faces the challenge of adapting to the evolving healthcare needs of an aging population. This study focuses on the education of medical residents in outpatient departments in Japan, a country with a rapidly aging society. The research aims to understand the perceptions and challenges medical residents face in outpatient management, highlighting the areas for potential improvement in their educational framework. Method This study involved first-year medical residents at Fuchu Hospital in Osaka, using thematic analysis based on relativist ontology and constructivist epistemology. Data were collected through field notes and reflection sheets, documenting residents' interactions with patients, learning difficulties, and personal reflections. Semi-structured interviews were conducted to gain profound insights into their experiences and views on outpatient management education. Results Three main themes emerged from the analysis: The experience of continuity of care, the view regarding comprehensive management, and the gap between purposes and learning content. Residents expressed concerns about the limited opportunities for continuous patient care, leading to challenges in managing chronic diseases effectively. The focus on organ-specific specialties in acute care hospitals resulted in a fragmented understanding of patient care, particularly for elderly patients with multimorbidity. Furthermore, the study identified a discrepancy between the educational goals of outpatient management and the actual content delivered, highlighting the need for more observational experiences and practical guidance in outpatient settings. Conclusion The findings suggest a pressing need for a more structured, comprehensive, and personalized approach to outpatient management education for medical residents. As aging populations continue to grow, it is vital to equip medical professionals with the skills and knowledge to manage a wide range of patient conditions effectively. Improving the educational framework in outpatient departments can enhance patient care quality and prepare medical residents to meet the challenges of an aging society. This study contributes valuable insights into improving medical education in outpatient settings, particularly in aging societies like Japan.

[Palliative Care Needs in Primary Health Care: Characteristics of Patients with Advanced Cancer and Dementia]

INTRODUCTION

The increase in life expectancy brought a higher prevalence of chronic diseases, with an emphasis on those who reached advanced stages and required palliative care. We aimed to characterize patients diagnosed with advanced neoplasms and/or dementia accompanied in primary health care and to test the sensitivity of two tools for identifying patients with palliative needs.

METHODS

We recruited three voluntary family physicians who provided data relative to 623 patients with active codification for neoplasm and/or dementia on the MIM@UF platform. We defined 'patient with palliative needs' as any patient with this codification in advanced stadium and made their clinical and sociodemographic characterization. Assuming the existence of advanced-stage disease as the gold standard, we calculated and compared the sensitivities of each of the tools under study: the surprise question, the question 'do you think this patient has palliative needs?' and an instrument that corresponded to identification by at least one of the questions.

RESULTS

Among the analyzed data, there were 559 (89.7%) active codifications of neoplasm and 64 (10.3%) of dementia; the prevalence of advanced neoplasm and dementia was 1.0% in the studied sample. The subgroup of patients with advanced dementia showed female sex predominance, an older age, and less access to health care. In both subgroups there was a scarcity of data related to education and income, and we observed polypharmacotherapy and multimorbidity. The sensitivity of the surprise question was 33.3% for neoplasia and 69.3% for dementia; of the new tool 50.0% for neoplasia and 92.3% for dementia; and, when used together, 55.6% for neoplasia and 92.3% for dementia.

CONCLUSION

Our results help characterize two subpopulations of patients in need of palliative care and advance with a possible tool for their identification, to be confirmed in a representative sample.

A scoping review of clusters of multiple long-term conditions in people with intellectual disabilities and factors impacting on outcomes for this patient group

People with intellectual disabilities (ID) are vulnerable to multiple long-term conditions (MLTC). However, in the UK, there are no individual strategies tailored for them. This study synthesised evidence on prevalence of MLTC in people with ID alongside risk factors, outcomes and preventative strategies. The scoping review used the tool Abstrackr to search retrieved articles from three bibliographic databases. Of 933 articles initially screened and further identified, 20 papers met our inclusion criteria. Our findings revealed significant data on prevalence of MLTC in people with ID across the studies, but very limited data on clusters or patterns of co-occurrence in this population. The majority of papers explored risk factors and strategies for prevention of MLTC, but far fewer compared outcomes by MLTC. The identified gaps in the literature indicate the need for further research to identify clusters of MLTC and tailored prevention strategies to reduce poor outcomes in this population.

Diabetes and Multiple Long-term Conditions: A Review of Our Current Global Health Challenge

Use of effective treatments and management programs is leading to longer survival of people with diabetes. This, in combination with obesity, is thus contributing to a rise in people living with more than one condition, known as multiple long-term conditions (MLTC or multimorbidity). MLTC is defined as the presence of two or more long-term conditions, with possible combinations of physical, infectious, or mental health conditions, where no one condition is considered as the index. These include a range of conditions such as cardiovascular diseases, cancer, chronic kidney disease, arthritis, depression, dementia, and severe mental health illnesses. MLTC has major implications for the individual such as poor quality of life, worse health outcomes, fragmented care, polypharmacy, poor treatment adherence, mortality, and a significant impact on health care services. MLTC is a challenge, where interventions for prevention and management are lacking a robust evidence base. The key research directions for diabetes and MLTC from a global perspective include system delivery and care coordination, lifestyle interventions and therapeutic interventions.

Multimorbidity is associated with lower total 24-hour movement activity among US adults

Objective

Having chronic conditions may result in reduced physical and cognitive function but less is known about multimorbidity with daily movement. We examined the association of multimorbidity and device-measured total daily movement in a nationally representative sample of US adults aged ≥ 30 years from the 2011-2014 National Health and Nutrition Examination Surveys.

Methods

Any multimorbidity (≥2 conditions) and complex multimorbidity (≥3 conditions across ≥ 3 body systems) were quantified using 16 chronic conditions via self-report and/or clinical thresholds. Total movement over 24-hours (Monitor-Independent Movement Summary units [MIMS-units]) was measured using a wrist-worn device (ActiGraph GT3X). Multivariable linear regression examined the association of 1) each chronic condition, 2) number of conditions, 3) any multimorbidity, and 4) complex multimorbidity with total movement. Covariates included age, gender, race/ethnicity, educational attainment, and smoking status.

Results

Among US adults (N = 7304, mean age: 53.2 ± 0.34 years, 53.2% female, 69.4% Non-Hispanic White), 62.2% had any multimorbidity with 34.2% having complex multimorbidity. After adjustment, a higher number of chronic conditions was associated with incrementally lower total movement (β MIMS-units [95% CI] compared to those with no chronic conditions; one: -419 [-772, -66], two: -605 [-933, -278], three: -1201 [-1506, -895], four: -1908 [-2351, -1465], 5+: -2972 [-3384, -2560]). Complex multimorbidity presence was associated with -1709 (95% CI: -2062, -1357) and -1269 (-1620, -918) lower total movement compared to those without multimorbidity and multimorbidity but not complex, respectively.

Conclusions

Multimorbidity was associated with lower 24-h movement among US adults and may be helpful for identifying adults at risk for low movement.

Caring for high-need patients

OBJECTIVE

We aimed to explore the construct of "high need" and identify common need domains among high-need patients, their care professionals, and healthcare organizations; and to describe the interventions that health care systems use to address these needs, including exploring the potential unintended consequences of interventions.

METHODS

We conducted a modified Delphi panel informed by an environmental scan. Expert stakeholders included patients, interdisciplinary healthcare practitioners (physicians, social workers, peer navigators), implementation scientists, and policy makers. The environmental scan used a rapid literature review and semi-structured interviews with key informants who provide healthcare for high-need patients. We convened a day-long virtual panel meeting, preceded and followed by online surveys to establish consensus.

RESULTS

The environmental scan identified 46 systematic reviews on high-need patients, 19 empirical studies documenting needs, 14 intervention taxonomies, and 9 studies providing construct validity for the concept "high need." Panelists explored the construct and terminology and established that individual patients' needs are unique, but areas of commonality exist across all high-need patients. Panelists agreed on 11 domains describing patient (e.g., social circumstances), 5 care professional (e.g., communication), and 8 organizational (e.g., staffing arrangements) needs. Panelists developed a taxonomy of interventions with 15 categories (e.g., care navigation, care coordination, identification and monitoring) directed at patients, care professionals, or the organization. The project identified potentially unintended consequences of interventions for high-need patients, including high costs incurred for patients, increased time and effort for care professionals, and identification of needs without resources to respond appropriately.

CONCLUSIONS

Care for high-need patients requires a thoughtful approach; differentiating need domains provides multiple entry points for interventions directed at patients, care professionals, and organizations. Implementation efforts should consider outlined intended and unintended downstream effects on patients, care professionals, and organizations.

A network-based study reveals multimorbidity patterns in people with type 2 diabetes

Patients with type 2 diabetes mellitus (T2DM) are at a heightened risk of living with multiple comorbidities. However, the comprehension of the multimorbidity characteristics of T2DM is still scarce. This study aims to illuminate T2DM's prevalent comorbidities and their interrelationships using network analysis. Using electronic medical records (EMRs) from 496,408 Chinese patients with T2DM, we constructed male and female global multimorbidity networks and age- and sex-specific networks. Employing diverse network metrics, we assessed the structural properties of these networks. Furthermore, we identified hub, root, and burst diseases within these networks while scrutinizing their temporal trends. Our findings uncover interconnected T2DM comorbidities manifesting as emergence in clusters or age-specific outbreaks and core diseases in each sex that necessitate timely detection and intervention. This data-driven methodology offers a comprehensive comprehension of T2DM's multimorbidity, providing hypotheses for clinical considerations in the prevention and therapeutic strategies.

Multimorbidity and complex multimorbidity in Brazilians with severe obesity

To investigate the prevalence of multimorbidity and complex multimorbidity and their association with sociodemographic and health variables in individuals with severe obesity. This is a baseline data analysis of 150 individuals with severe obesity (body mass index ≥ 35.0 kg/m2) aged 18-65 years. The outcomes were multimorbidity and complex multimorbidity. Sociodemographic, lifestyle, anthropometric and self-perceived health data were collected. Poisson multiple regression was conducted to identify multimorbidity risk factors. The frequency of two or more morbidities was 90.7%, three or more morbidities was 76.7%, and complex multimorbidity was 72.0%. Living with four or more household residents was associated with ≥ 3 morbidities and complex multimorbidity. Fair and very poor self-perceived health was associated with ≥ 2 morbidities, ≥ 3 morbidities and complex multimorbidity. A higher BMI range (45.0-65.0 kg/m2) was associated with ≥ 2 morbidities and ≥ 3 morbidities. Anxiety (82.7%), varicose veins of lower limbs (58.7%), hypertension (56.0%) were the most frequent morbidities, as well as the pairs and triads including them. The prevalence of multimorbidity and complex multimorbidity in individuals with severe obesity was higher and the risk for multimorbidity and complex multimorbidity increased in individuals living in households of four or more residents, with fair or poor/very poor self-perceived health and with a higher BMI.

Relationship between severe mental illness and physical multimorbidity: a meta-analysis and call for action

BACKGROUND

People with severe mental illness (SMI) have a higher prevalence of several chronic physical health conditions, and the prevalence of physical multimorbidity is expected to rise. The aim of this study was to assess the strength of the association between SMI and physical multimorbidity.

STUDY SELECTION AND ANALYSIS

We systematically searched PubMed/Medline, Scopus, Embase, Web of Science, PsycINFO and the behavioural sciences collection databases, from inception to 31 January 2023, for studies that investigated the association between SMI and physical multimorbidity. Humans of any age either clinically diagnosed and/or currently receiving treatment for SMI, specified as schizophrenia (and related psychotic disorders), bipolar disorder and psychotic depression, were eligible. Data from studies selected for inclusion were converted into ORs, with a subsequent meta-analysis conducted.

FINDINGS

We included 19 studies with a total of 194 123 patients with SMI with different diagnoses and drawn from the general population. The pooled OR for physical multimorbidity in people with versus without SMI was 1.84 (95% CI 1.33 to 2.54), with the analysis indicating a high level of heterogeneity (98.38%). The other 15 studies included in the systematic review for which it was not possible to conduct a meta-analysis showed strong associations between SMI and physical multimorbidity.

CONCLUSIONS

The current evidence highlights the link between SMI and physical multimorbidity. A multidisciplinary approach is now urgent to develop the best models of services tailored to patients with SMI with physical multimorbidities to improve physical, mental and social outcomes. PROSPERO registration number CRD42023395165.

An Overview of Systemic Health Factors Related to Rapid Oral Health Deterioration among Older People

The oral health of older individuals can be negatively impacted by various systemic health factors, leading to rapid oral health deterioration. This paper aims to present an overview of the published evidence on systemic health factors that contribute to rapid oral health deterioration in older individuals, and to explore the implications of these factors for both general healthcare and oral healthcare provision. Older people are at risk of experiencing adverse reactions to medications due to multimorbidity, polypharmacy, and changes in pharmacokinetics and pharmacodynamics. Hyposalivation, a significant side effect of some medications, can be induced by both the type and number of medications used. Frailty, disability, sarcopenia, care dependency, and limited access to professional oral healthcare can also compromise the oral health of older people. To prevent rapid oral health deterioration, a comprehensive approach is required that involves effective communication between oral healthcare providers, other healthcare providers, and informal caregivers. Oral healthcare providers have a responsibility to advocate for the importance of maintaining adequate oral health and to raise awareness of the serious consequences of weakened oral health. By doing so, we can prevent weakened oral health from becoming a geriatric syndrome.

Multimorbidity patterns and health-related quality of life in Jamaican adults: a cross sectional study exploring potential pathways

Introduction

Multimorbidity and health-related quality of life (HRQoL) are intimately linked. Multiple chronic conditions may adversely affect physical and mental functioning, while poorer HRQoL may contribute to the worsening course of diseases. Understanding mechanisms through which specific combinations of diseases affect HRQoL outcomes can facilitate identification of factors which are amenable to intervention. Jamaica, a middle-income country with high multimorbidity prevalence, has a health service delivery system dominated by public sector provision via a broad healthcare network. This study aims to examine whether multimorbidity classes differentially impact physical and mental dimensions of HRQoL in Jamaicans and quantify indirect effects on the multimorbidity-HRQoL relationship that are mediated by health system factors pertaining to financial healthcare access and service use.

Materials and methods

Latent class analysis (LCA) was used to estimate associations between multimorbidity classes and HRQoL outcomes, using latest available data from the nationally representative Jamaica Health and Lifestyle Survey 2007/2008 (N = 2,551). Multimorbidity measurement was based on self-reported presence/absence of 11 non-communicable diseases (NCDs). HRQoL was measured using the 12-item short-form (SF-12) Health Survey. Mediation analyses guided by the counterfactual approach explored indirect effects of insurance coverage and service use on the multimorbidity-HRQoL relationship.

Results

LCA revealed four profiles, including a Relatively Healthy class (52.7%) characterized by little to no morbidity and three multimorbidity classes characterized by specific patterns of NCDs and labelled Metabolic (30.9%), Vascular-Inflammatory (12.2%), and Respiratory (4.2%). Compared to the Relatively Healthy class, Vascular-Inflammatory class membership was associated with lower physical functioning (β = -5.5; p < 0.001); membership in Vascular-Inflammatory (β = -1.7; p < 0.05), and Respiratory (β = -2.5; p < 0.05) classes was associated with lower mental functioning. Significant mediated effects of health service use, on mental functioning, were observed for Vascular-Inflammatory (p < 0.05) and Respiratory (p < 0.05) classes.

Conclusion

Specific combinations of diseases differentially impacted HRQoL outcomes in Jamaicans, demonstrating the clinical and epidemiological value of multimorbidity classes for this population, and providing insights that may also be relevant to other settings. To better tailor interventions to support multimorbidity management, additional research is needed to elaborate personal experiences with healthcare and examine how health system factors reinforce or mitigate positive health-seeking behaviours, including timely use of services.

Prevalence of multimorbidity and its associations with hospitalisation or death in Japan 2014-2019: a retrospective cohort study using nationwide medical claims data in the middle-aged generation

OBJECTIVE

To describe the prevalence of multimorbidity and its associations with clinical outcomes across age groups.

DESIGN

Retrospective cohort study using nationwide medical claims data.

SETTING

Carried out in Japan between April 2014 and March 2019.

PARTICIPANTS

N=246 671 Japanese individuals aged 20-74 enrolled in the health insurance were included into the baseline data set for fiscal year (FY) 2014. Of those, N=181 959 individuals were included into the cohort data set spanning FY2014-FY2018.

EXPOSURES

Multimorbidity was defined as having ≥2 of 15 chronic conditions according to the International Classification of Diseases 10th Revision codes of the Charlson Comorbidity Index.

PRIMARY AND SECONDARY OUTCOMES

Primary outcome: the standardised prevalence of multimorbidity across age groups was evaluated using data from FY2014 and extrapolated to the Japanese total population.

SECONDARY OUTCOME

hospitalisation or death events were traced by month using medical claims data and insurer enrolment data. Associations between multimorbidity and 5-year hospitalisation and/or death events across age groups were analysed using a Cox regression model.

RESULTS

The standardised prevalence rate of multimorbidity in the nationwide Japanese total population was estimated to 26.1%. The prevalence rate with age was increased, approximately 5% (ages 20-29), 10% (30-39), 20% (40-49), 30% (50-59), 50% (60-69) and 60% (70-74). Compared with individuals aged 20-39 without multimorbidity, those with multimorbidity had a higher incidence of clinical events in any age group (HR=2.43 (95% CI 2.30 to 2.56) in ages 20-39, HR=2.55 (95% CI 2.47 to 2.63) in ages 40-59 and HR=3.41 (95% CI 3.23 to 3.53) in ages ≥60). The difference in the incidence of clinical events between multimorbidity and no multimorbidity was larger than that between age groups.

CONCLUSIONS

Multimorbidity is already prevalent in the middle-aged generation and is associated with poor clinical outcomes. These findings underscore the significance of multimorbidity and highlight the urgent need for preventive intervention at the public healthcare level.

Adjusted morbidity groups and survival: a retrospective cohort study of primary care patients with chronic conditions

BACKGROUND

Chronic conditions are one of the main determinants of frailty, functional disability, loss of quality of life and the number one cause of death worldwide. This study aimed to describe the survival of patients with chronic conditions who were followed up in primary care according to the level of risk by adjusted morbidity groups and to analyse the effects of sex, age, clinician and care factors on survival.

METHODS

This was a longitudinal observational study of a retrospective cohort of patients with chronic conditions identified by the adjusted morbidity group stratifier of the electronic medical records in a primary health centre of the Region of Madrid, which has an assigned population of 18,107 inhabitants. The follow-up period was from June 2015 to June 2018. A description of survival according to the Kaplan-Meier method and Cox proportional hazards multivariate regression model was used to analyse the effects of sex, age, clinician and care factors.

RESULTS

A total of 9,866 patients with chronic conditions were identified; 77.4% (7,638) had a low risk, 18.1% (1,784) had a medium risk, and 4.5% (444) had a high risk according to the adjusted morbidity groups. A total of 477 patients with chronic conditions died (4.8%). The median survival was 36 months. The factors associated with lower survival were age over 65 years (hazard ratio [HR] = 1.3; 95% confidence interval [CI] = 1.1-1.6), receiving palliative care (HR = 3.4; 95% CI = 2.6-4.5), high versus low risk level (HR = 2.4; 95% CI = 1.60-3.7), five chronic conditions or more (HR = 1.5; 95% CI = 1.2-2), complexity index (HR = 1.01; 95% CI = 1.02-1.04) and polymedication (HR = 2.6; 95% CI = 2.0-3.3).

CONCLUSIONS

There was a gradual and significant decrease in the survival of patients with chronic conditions according to their level of risk as defined by adjusted morbidity groups. Other factors, such as older age, receiving palliative care, high number of chronic conditions, complexity, and polymedication, had a negative effect on survival. The adjusted morbidity groups are useful in explaining survival outcomes and may be valuable for clinical practice, resource planning and public health research.

The implications of defining obesity as a disease: a report from the Association for the Study of Obesity 2021 annual conference

Unlike various countries and organisations, including the World Health Organisation and the European Parliament, the United Kingdom does not formally recognise obesity as a disease. This report presents the discussion on the potential impact of defining obesity as a disease on the patient, the healthcare system, the economy, and the wider society. A group of speakers from a wide range of disciplines came together to debate the topic bringing their knowledge and expertise from backgrounds in medicine, psychology, economics, and politics as well as the experience of people living with obesity. The aim of their debate was not to decide whether obesity should be classified as a disease but rather to explore what the implications of doing so would be, what the gaps in the available data are, as well as to provide up-to-date information on the topic from experts in the field. There were four topics where speakers presented their viewpoints, each one including a question-and-answer section for debate. The first one focused on the impact that the recognition of obesity could have on people living with obesity regarding the change in their behaviour, either positive and empowering or more stigmatising. During the second one, the impact of defining obesity as a disease on the National Health Service and the wider economy was discussed. The primary outcome was the need for more robust data as the one available does not represent the actual cost of obesity. The third topic was related to the policy implications regarding treatment provision, focusing on the public's power to influence policy. Finally, the last issue discussed, included the implications of public health actions, highlighting the importance of the government's actions and private stakeholders. The speakers agreed that no matter where they stand on this debate, the goal is common: to provide a healthcare system that supports and protects the patients, strategies that protect the economy and broader society, and policies that reduce stigma and promote health equity. Many questions are left to be answered regarding how these goals can be achieved. However, this discussion has set a good foundation providing evidence that can be used by the public, clinicians, and policymakers to make that happen.

Multimorbidity and statin prescription for primary prevention of cardiovascular diseases: A cross-sectional study in general practice in France

Background

Statins are a first line, evidence-based yet underprescribed treatment for cardiovascular primary prevention. In primary care settings, multimorbidity is a complex situation which makes it difficult to apply prevention guidelines.

Aim

To assess the associations between multimorbidity and prescription of statins in accordance with the 2016 ESC recommendations ("appropriate prescription"), and to identify the factors and conditions associated with these prescriptions.

Design and setting

Cross-sectional prospective study in the French region of Rhône-Alpes among 40 general practitioners and their patients.

Methods

We examined the association between appropriate statin prescription and several patient characteristics, including multimorbidity, using multivariate logistic regression models.

Results

Between August 2017 and February 2019, 327 patients were included in the study. Seventy-four (22.6%) were on statin medication and 199 (60.9%) exhibited multimorbidity, defined as ≥2 diseases. Only 22.5% of eligible patients were prescribed statins for primary prevention. Diabetes was most strongly associated with appropriate statin prescription (aOR 8.10, CI 95: 3.81-17.80). Multimorbidity was not associated with appropriate statin prescription (aOR 1.31, CI 95: 0.54-3.26), except in the presence of diabetes which defined diabetic multimorbidity (aOR 10.46, CI 95: 4.87-23.35). Conversely, non-diabetic multimorbidity was associated with lower odds of being appropriately prescribed a statin (aOR 0.26, CI 95: 0.12-0.56).

Conclusion

Multimorbidity, in itself, does not seem to be a determinant factor for appropriate statin prescription. The latter appears to be determined by a patient's type of multimorbidity, especially the presence or not of diabetes. Differentiating between diabetic and non-diabetic multimorbidity may be a pragmatic way for GPs to improve primary prevention in a patient-centered and shared decision-making approach.

A conceptual framework for characterising lifecourse determinants of multiple long-term condition multimorbidity

Objective

Social, biological and environmental factors in early-life, defined as the period from preconception until age 18, play a role in shaping the risk of multiple long-term condition multimorbidity. However, there is a need to conceptualise these early-life factors, how they relate to each other, and provide conceptual framing for future research on aetiology and modelling prevention scenarios of multimorbidity. We develop a conceptual framework to characterise the population-level domains of early-life determinants of future multimorbidity.

Method

This work was conducted as part of the Multidisciplinary Ecosystem to study Lifecourse Determinants and Prevention of Early-onset Burdensome Multimorbidity (MELD-B) study. The conceptualisation of multimorbidity lifecourse determinant domains was shaped by a review of existing research evidence and policy, and co-produced with public involvement via two workshops.

Results

Early-life risk factors incorporate personal, social, economic, behavioural and environmental factors, and the key domains discussed in research evidence, policy, and with public contributors included adverse childhood experiences, socioeconomics, the social and physical environment, and education. Policy recommendations more often focused on individual-level factors as opposed to the wider determinants of health discussed within the research evidence. Some domains highlighted through our co-production process with public contributors, such as religion and spirituality, health screening and check-ups, and diet, were not adequately considered within the research evidence or policy.

Conclusions

This co-produced conceptualisation can inform research directions using primary and secondary data to investigate the early-life characteristics of population groups at risk of future multimorbidity, as well as policy directions to target public health prevention scenarios of early-onset multimorbidity.

Association of lifestyle and sociodemographic factors on multimorbidity: a cross-sectional study in Portugal

Background

Lifestyle factors are widely recognized as modifiers and major risk factors for non-communicable diseases. Previous studies on the prevalence of multimorbidity in Portugal predict an unfavourable reality. The aim of the present study was to analyse 1) the prevalence of multimorbidity in Portugal and 2) the association of individuals’ lifestyles and sociodemographic factors with multimorbidity.

Methods

A cross-sectional, population-wide study was conducted on a representative sample of the general population of Portuguese adults aged ≥ 20 years. Categorical variables were described by their respective absolute and relative frequencies (n (%)). All variables with a p-value < 20% were included in the multiple logistic regression model. The variables were removed one by one in descending order of p-value (p) until the model contained only significant variables. The results are presented using the odds ratio and 95% confidence intervals. P-values ​​ < 5% were considered significant.

Results

The prevalence of multimorbidity was 48.9% (n = 436), and the odds of multimorbidity increased 4% (p < 0.001) for each year of increase in age. Participants with reasonable general health status had higher odds of multimorbidity (Odds ratio (OR) = 3.04; p < 0.001), and those with poor or very poor general health status had even higher odds (OR = 9.14; p < 0.001). Compared to those who never smoked, participants who quit smoking ≥ 1 year presented an increase of 91% (p = 0.005) in the odds of multimorbidity. Individuals with no good-quality sleep, non-moderate screen time, or non-moderate stress level had higher odds of multimorbidity (OR = 1.98; OR = 1.88; OR = 2.22, respectively. p < 0.001).

Conclusions

This study presented a new approach to multimorbidity in Portugal. Population-based, multidimensional lifestyle interventions are needed. It seems necessary to optimize and adjust measures to prevent non-communicable diseases to improve health in Portugal. In the future, longitudinal studies will be an asset to reinforce and clarify these conclusions.

Defining and measuring multimorbidity in primary care in Singapore: Results of an online Delphi study

Multimorbidity, common in the primary care setting, has diverse implications for both the patient and the healthcare system. However, there is no consensus on the definition of multimorbidity globally. Thus, we aimed to conduct a Delphi study to gain consensus on the definition of multimorbidity, the list and number of chronic conditions used for defining multimorbidity in the Singapore primary care setting. Our Delphi study comprised three rounds of online voting from purposively sampled family physicians in public and private settings. Delphi round 1 included open-ended questions for idea generation. The subsequent two rounds used questions with pre-selected options. Consensus was achieved based on a pre-defined criteria following an iterative process. The response rates for the three rounds were 61.7% (37/60), 86.5% (32/37) and 93.8% (30/32), respectively. Among 40 panellists who responded, 46.0% were 31-40 years old, 64.9% were male and 73.0% were from the public primary healthcare setting. Based on the findings of rounds 1, 2 and 3, consensus on the definition of a chronic condition, multimorbidity and finalised list of chronic conditions were achieved. For a condition to be chronic, it should last for six months or more, be recurrent or persistent, impact patients across multiple domains and require long-term management. The consensus-derived definition of multimorbidity is the presence of three or more chronic conditions from a finalised list of 23 chronic conditions. We anticipate that our findings will inform multimorbidity conceptualisation at the national level, standardise multimorbidity measurement in primary care and facilitate resource allocation for patients with multimorbidity.

A mixed-methods systematic review of nurse-led interventions for people with multimorbidity

AIMS

To identify types of nurse-led interventions for multimorbidity and which outcomes are positively affected by them.

DESIGN

Mixed-methods systematic review following the Joanna Briggs Institute (JBI) methods for convergent-integrated reviews.

PROSPERO ID

CRD42020197956.

DATA SOURCES

Cochrane CENTRAL, CINAHL, Embase and MEDLINE were searched in October 2020. Grey literature sources included OpenGrey, the Journal of Multimorbidity and Comorbidity and reference mining.

REVIEW METHODS

English-language reports of nurse-led interventions for people with multimorbidity were included based on author consensus. Two reviewers performed independent quality appraisal using JBI tools. Data were extracted and synthesized using a pre-existing taxonomy of interventions and core outcome set.

RESULTS

Twenty studies were included, with a median summary quality score of 77.5%. Interventions were mostly case-management or transitional care interventions, with nurses in advanced practice, support to self-manage conditions, and an emphasis on continuity of care featuring frequently. Patient-centred outcomes such as quality of healthcare and health-related quality of life were mostly improved, with mixed effects on healthcare utilization, costs, mortality and other outcomes.

CONCLUSION

Interventions such as case management are agreeable to patients and transitional care interventions may have a small positive impact on healthcare utilization. Interventions include long-term patient management or short-term interventions targeted at high-risk junctures. These interventions feature nurses in advanced practice developing care plans in partnership with patients, to simplify and improve the quality of care both in the long and short-term.

IMPACT

This is the first mixed-methods review which includes all types of nurse-led interventions for multimorbidity and does not focus on specific comorbidities or elderly/frail populations. Using adapted consensus-developed frameworks for interventions and outcomes, we have identified the common features of interventions and their overall typology. We suggest these interventions are of value to patients and healthcare systems but require localization and granular evaluation of their components to maximize potential benefits.

[Multimorbidity in patient's care - definitions, strategies and limitations]

The challenge of multimorbidity, the occurrence of multiple medical conditions, lies in its complexity, considering their type and severity, their interactions, and the patient's social status and characteristics. Although the number of combinations appears unlimited, there emerge so-called multimorbidity patterns, that group diseases, that often coincide.The prevalence of multimorbidity will increase dramatically because of the demographic change and the medical progress, leading to exploding costs in healthcare. The definition and the therapeutic approaches of the field are ambiguous, while it also lacks an established assessment.The complex needs of a patient with multimorbidity are not addressed appropriately with the established one-disease-approach. Clinical guidelines can suggest conflicting treatment strategies, which result in decision dilemmas in daily work.Time, communication and decisions adapted to the patient's situation are the key to a successful treatment of multimorbidity. An integrated approach must be based on a comprehensive geriatric assessment. Action strategies and the integration of guidelines are needed and will support the clinician during the decision-making processes. Furthermore, clinical studies should include older adults with multimorbidity and should particularly consider their relevant outcomes.Geroscience is a new research area that addresses the hallmarks of aging with therapeutic approaches to delay or even avoid the onset of multimorbidity.

Alternative Healthy Eating Index-2010 and Incident Non-Communicable Diseases: Findings from a 15-Year follow up of Women from the 1973–78 Cohort of the Australian Longitudinal Study on Women’s Health

Non-communicable diseases (NCDs) and multimorbidity (≥two chronic conditions), are increasing globally. Diet is a risk factor for some NCDs. We aimed to investigate the association between diet quality (DQ) and incident NCDs. Participants were from the Australian Longitudinal Study on Women’s Health 1973–78 cohort with no NCD and completed dietary data at survey 3 (2003, aged 25–30 years) who responded to at least one survey between survey 4 (2006) and survey 8 (2018). DQ was measured by the Alternative Healthy Eating Index-2010 (AHEI-2010). Outcomes included coronary heart disease (CHD), hypertension (HT), asthma, cancer (excluding skin cancer), diabetes mellitus (DM), depression and/or anxiety, multimorbidity, and all-cause mortality. Repeated cross-sectional multivariate logistic regressions were performed to investigate the association between baseline DQ and NCDs over 15 years. The AHEI-2010 mean (±sd) for participants (n = 8017) was 51.6 ± 11.0 (range: 19–91). There was an inverse association between AHEI-2010 and incident asthma at survey 4 (OR_Q5–Q1: 0.75, 95% CI: 0.57, 0.99). Baseline DQ did not predict the occurrence of any NCDs or multimorbidity between the ages of 25–45 years. Further well-planned, large prospective studies conducted in young women are needed to explore dietary risk factors before the establishment of NCDs.

Data-driven patient stratification of UK Biobank cohort suggests five endotypes of multimorbidity

Multimorbidity generally refers to concurrent occurrence of multiple chronic conditions. These patients are inherently at high risk and often lead a poor quality of life due to delayed treatments. With the emergence of personalized medicine and stratified healthcare, there is a need to stratify patients right at the primary care setting. Here we developed multimorbidity analysis pipeline (MulMorPip), which can stratify patients into multimorbid subgroups or endotypes based on their lifetime disease diagnosis and characterize them based on demographic features and underlying disease-disease interaction networks. By implementing MulMorPip on UK Biobank cohort, we report five distinct molecular subclasses or endotypes of multimorbidity. For each patient, we calculated the existence of broad disease classes defined by Charlson's comorbidity classification using the International Classification of Diseases-10 encoding. We then applied multiple correspondence analysis in 77 524 patients from UK Biobank, who had multimorbidity of more than one disease, which resulted in five multimorbid clusters. We further validated these clusters using machine learning and were able to classify 20% model-blind test set patients with an accuracy of 97% and an average Jaccard similarity of 84%. This was followed by demographic characterization and development of interlinking disease network for each cluster to understand disease-disease interactions. Our identified five endotypes of multimorbidity draw attention to dementia, stroke and paralysis as important drivers of multimorbidity stratification. Inclusion of such patient stratification at the primary care setting can help general practitioners to better observe patients' multiple chronic conditions, their risk stratification and personalization of treatment strategies.

A systematic literature review of patient self-assessment instruments concerning quality of primary care in multiprofessional clinics

BACKGROUND

Quality of care remains a priority issue and is correlated with patient experience. Measuring multidimensional patient primary care experiences in multiprofessional clinics requires a robust instrument. Although many exist, little is known about their quality.

OBJECTIVE

To identify patient perception instruments in multiprofessional primary care and evaluate their quality.

METHODS

Systematic review using Medline, Pascal, PsycINFO, Google Scholar, Cochrane, Scopus, and CAIRN. Eligible articles developed, evaluated, or validated 1 or more self-assessment instruments. The instruments had to measure primary care delivery, patient primary care experiences and assess at least 3 quality-of-care dimensions. The COnsensus-based Standards for the selection of health status Measurement Instruments (COSMIN) checklist was used to assess methodological quality of included studies. Instrument measurement properties were appraised using 3 possible quality scores. Data were combined to provide best-evidence synthesis based on the number of studies, their methodological quality, measurement property appraisal, and result consistency. Subscales used to capture patient primary care experiences were extracted and grouped into the 9 Institute of Medicine dimensions.

RESULTS

Twenty-nine articles were found. The included instruments captured many subscales illustrating the diverse conceptualization of patient primary care experiences. No included instrument demonstrated adequate validity and the lack of scientific methodology for assessing reliability made interpreting validity questionable. No study evaluated instrument responsiveness.

CONCLUSION

Numerous patient self-assessment instruments were identified capturing a wide range of patient experiences, but their measurement properties were weak. Research is required to develop and validate a generic instrument for assessing quality of multiprofessional primary care.

TRIAL REGISTRATION

Not applicable.

Health and Care Dependency of Older Adults in Dresden, Germany: Results from the LAB60+ Study

As the population in Europe ages, an increased focus on the health of older adults is necessary. The purpose of the population-based LAB60+ study was to examine the current health and care situation of the population of older adults in Dresden, Germany, and to assess the effect of age, gender, and socioeconomic status (SES) on health outcomes. In the first half of 2021, 2399 out of 6004 randomly sampled residents of Dresden aged 60 years or older answered questions on their chronic conditions, care dependency, health-related quality of life (HRQoL), and well-being, among others. Of the participants, 91.6% were afflicted with at least one chronic condition, and 73.1% had multimorbidities. More than one-tenth (11.3%) of participants were care dependent. Lower levels of HRQoL and well-being were observed compared to a published German reference population, perhaps because of the ongoing COVID-19 pandemic. Gender differences were observed for some chronic health conditions, and women had a higher risk for lower HRQoL, well-being, and depressivity compared to men. A low SES was associated with a higher risk of the vast majority of health outcomes. Particularly, socioeconomic factors and gender-related inequalities should be considered for the development of prevention and health-promoting measures during late life.

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.

Analysis of Epigenetic Age Acceleration and Healthy Longevity Among Older US Women

IMPORTANCE

Accelerated biological aging is associated with decreased physical capability and cognitive functioning, which are associated with increased risk of morbidity and mortality.

OBJECTIVE

We investigated associations between epigenetic age acceleration (EAA), a biomarker associated with aging, and healthy longevity among older women.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study was a secondary analysis of participants in the Women's Health Initiative (WHI) who were eligible to survive to age 90 years by September 30, 2020. Participants were located in multiple centers. This study was restricted to women with genome-wide DNA methylation data, generated from baseline blood samples within 3 WHI ancillary studies. Median (IQR) follow-up times from baseline were 21.6 (19.6-22.9) years and 21.4 (19.8-22.7) years for women who survived to age 90 years with and without intact mobility, respectively, and 13.2 (8.8-16.7) for women who did not survive to age 90 years. Data were analyzed from December 2020 to July 2021.

EXPOSURES

EAA was estimated using 4 established "clocks": Horvath pantissue, Hannum, Pheno, and Grim.

MAIN OUTCOMES AND MEASURES

Using multinomial logistic regression, odds ratios (ORs) and 95% CIs were estimated for 3 healthy longevity outcomes for each clock: survival to age 90 years with intact mobility, survival to age 90 years without intact mobility, and no survival to age 90 years.

RESULTS

Among 1813 women, there were 464 women (mean [SD] age at baseline, 71.6 [3.5] years) who survived to age 90 years with intact mobility and cognitive functioning, 420 women (mean [SD] age at baseline, 71.3 [3.2] years) who survived to age 90 years without intact mobility and cognitive functioning, and 929 women (mean [SD] age at baseline, 70.2 [3.4] years) who did not survive to age 90 years. Women who survived to age 90 years with intact mobility and cognitive function were healthier at baseline compared with women who survived without those outcomes or who did not survive to age 90 years (eg, 143 women [30.8%] vs 101 women [24.0%] and 202 women [21.7%] with 0 chronic conditions). The odds of surviving to age 90 years with intact mobility were lower for every 1 SD increase in EAA compared with those who did not survive to age 90 years as measured by AgeAccelHorvath (OR, 0.82; 95% CI, 0.69-0.96; P = .01), AgeAccelHannum (OR, 0.67; 95% CI, 0.56-0.80; P < .001), AgeAccelPheno (OR, 0.60; 95% CI, 0.51-0.72; P < .001), and AgeAccelGrim (OR, 0.68; 95% CI, 0.55-0.84; P < .001). ORs were similar for women who survived to age 90 years with intact mobility and cognitive function (eg, AgeAccelHorvath: OR per 1 SD increase in EAA, 0.83; 95% CI, 0.71-0.98; P = .03) compared with women who did not survive to age 90 years.

CONCLUSIONS AND RELEVANCE

These findings suggest that EAA may be a valid biomarker associated with healthy longevity among older women and may be used for risk stratification and risk estimation of future functional and cognitive aging. Outcomes suggest that future studies may focus on the potential for public health interventions to counteract EAA and its association with poor health outcomes to lower disease burden while increasing longevity.

How do general practitioners handle complexities? A team ethnographic study in Japan

BACKGROUND

General practitioners (GPs) are often faced with complex problems, including patients with socio-economic and medical problems. However, the methods they use to approach these complexities are still not understood. We speculated that elucidating these methods using complex adaptive systems (CAS) methodology to comprehensively assess GPs' daily activities would contribute to improving the professional development of GPs. This study aimed to clarify how expert GPs handle complex problems and adapt to their community context through the ethnography of GPs and other healthcare professionals in terms of CAS.

METHODS

We adopted the interdisciplinary team-ethnographic research approach. Five hospitals and four clinics in Japan which were considered to employ expert GPs were selected by purposive sampling. 62 individuals of various backgrounds working in these nine facilities were interviewed. Using field notes and interview data, the researchers iteratively discussed the adequacy of our interpretations. The first author (JH) prepared a draft report, which was reviewed by the GPs at the participating facilities. Through critical and iterative consideration of the different insights obtained, the final findings emerged together with representative data.

RESULTS

We identified four approaches used by GPs to deal with complexities. First, GPs treat patients with complex problems as a whole being and address their problems multi-directionally. Second, GPs build horizontal, trusting relationships with other healthcare professionals and stakeholders, and thereby reduce the degree of complexity of problems. Third, GPs change the learning climate while committing to their own growth based on societal needs and by acting as role models for other professionals through daily interpersonal facilitation. Fourth, GPs share community vision with multi-professionals and thereby act as a driving force for organizational change. These various interactions among GPs, healthcare professionals, organizations and communities resulted in systematization of the healthcare and welfare network in their community.

CONCLUSIONS

Expert GPs developed interconnected multidimensional systems in their community health and welfare networks to adapt to fluctuating social realities using four approaches. GPs' work environment may be considered as a complex adaptive system (CAS) and the approach of GPs to complexities is CAS-based. Our findings are expected to have practical applications for GPs.

Different definitions of multimorbidity and their effect on prevalence rates: a retrospective study in German general practices

BACKGROUND

Multimorbidity is common among general practice patients and increases a general practitioner's (GP's) workload. But the extent of multimorbidity may depend on its definition and whether a time delimiter is included in the definition or not.

AIMS

The aims of the study were (1) to compare practice prevalence rates yielded by different models of multimorbidity, (2) to determine how a time delimiter influences the prevalence rates and (3) to assess the effects of multimorbidity on the number of direct and indirect patient contacts as an indicator of doctors' workload.

METHODS

This retrospective observational study used electronic medical records from 142 German general practices, covering 13 years from 1994 to 2007. The four models of multimorbidity ranged from a simple definition, requiring only two diseases, to an advanced definition requiring at least three chronic conditions. We also included a time delimiter for the definition of multimorbidity. Descriptive statistics, such as means and correlation coefficients, were applied.

FINDINGS

The annual percentage of multimorbid primary care patients ranged between 84% (simple model) and 16% (advanced model) and between 74% and 13% if a time delimiter was included. Multimorbid patients had about twice as many contacts annually than the remainder. The number of contacts were different for each model, but the ratio remained similar. The number of contacts correlated moderately with patient age (r = 0.35). The correlation between age and multimorbidity increased from model to model up to 0.28 while the correlations between contacts and multimorbidity varied around 0.2 in all four models.

CONCLUSION

Multimorbidity seems to be less prevalent in primary care practices than usually estimated if advanced definitions of multimorbidity and a temporal delimiter are applied. Although multimorbidity increases in any model a doctor's workload, it is especially the older person with multiple chronic diseases who is a challenge for the GP.

The Perceived Risk of Hospitalization in Primary Health Care – The Importance of Multidimensional Assessment

Ageing has increased the use of health services, with a corresponding rise in avoidable hospitalizations. We aimed to assess and characterize the perceived risk of hospitalization in primary health care (PHC). 118 individuals aged ≥65 years, PHC patients, were assessed using the Community Risk Assessment Instrument by their General Practitioner, who identified their perceived risk of hospitalization, at one year. The instrument is composed of three domains (mental state, daily living activities (ADLs) state and medical state). Multivariate logistic regression was used to identify the best model to predict the risk of hospitalization. Four models were estimated, one for each domain and one with all the variables of the instrument. 58.5% were identified as being at risk of hospitalization. The best predictive models are those that include functionality assessment variables (ADL model and Community Assessment of Risk Instrument model). The model that includes all the variables of three domains presents the best predictive value. Mobility problems (Odds Ratio (OR) 16.18 [CI: 1.63–160.53]), meal preparation (OR 10.93 [CI: 1.59–75.13]), communication (OR 6.91 [CI: 1.37–34.80]) and palliative care (OR 4.84 [CI: 1.14–20.58]) are the best predictors of hospitalization risk. The use of multidimensional assessment tools can allow the timely identification of people at risk, contributing to a reduction in hospitalizations.

How do multi-morbidity and polypharmacy affect general practice attendance and referral rates? A retrospective analysis of consultations

Background

As prevalence of multimorbidity and polypharmacy rise, health care systems must respond to these challenges. Data is needed from general practice regarding the impact of age, number of chronic illnesses and medications on specific metrics of healthcare utilisation.

Methods

This was a retrospective study of general practices in a university-affiliated education and research network, consisting of 72 practices. Records from a random sample of 100 patients aged 50 years and over who attended each participating practice in the previous two years were analysed. Through manual record searching, data were collected on patient demographics, number of chronic illnesses and medications, numbers of attendances to the general practitioner (GP), practice nurse, home visits and referrals to a hospital doctor. Attendance and referral rates were expressed per person-years for each demographic variable and the ratio of attendance to referral rate was also calculated.

Results

Of the 72 practices invited to participate, 68 (94%) accepted, providing complete data on a total of 6603 patients’ records and 89,667 consultations with the GP or practice nurse; 50.1% of patients had been referred to hospital in the previous two years. The attendance rate to general practice was 4.94 per person per year and the referral rate to the hospital was 0.6 per person per year, giving a ratio of over eight attendances for every referral. Increasing age, number of chronic illnesses and number of medications were associated with increased attendance rates to the GP and practice nurse and home visits but did not significantly increase the ratio of attendance to referral rate.

Discussion

As age, morbidity and number of medications rise, so too do all types of consultations in general practice. However, the rate of referral remains relatively stable. General practice must be supported to provide person centred care to an ageing population with rising rates of multi-morbidity and polypharmacy.

The effect of disease onset chronology on mortality among patients with multimorbidity: A Danish nationwide register study

Background

Multimorbidity is associated with increased mortality. Certain combinations of diseases are known to be more lethal than others, but the limited knowledge of how the chronology in which diseases develop impacts mortality may impair the development of effective clinical interventions for patients with multimorbidity.

Objective

To explore if in multimorbidity the chronology of disease onset is associated with mortality. Design: A prospective nationwide cohort study, including 3,986,209 people aged ≥18 years on 1 January 2000, was performed. We included ten diagnosis groups: lung, musculoskeletal, endocrine, mental, cancer, neurological, gastrointestinal, cardiovascular, kidney, and sensory organs. We defined multimorbidity as the presence of at least two diagnoses from two diagnosis groups (out of ten). To determine mortality, logistic regression models were used to calculate odds ratios (OR) and ratio of ORs (RORs).

Results

For most combinations of multimorbidity, the chronology of disease onset does not change mortality. However, when multimorbidity included mental health diagnoses, mortality was in general higher if the mental health diagnosis appeared first. If multimorbidity included heart and sensory diagnoses, mortality was higher if these developed second. For the majority of multimorbidity combinations, there was excess mortality if multimorbidity was diagnosed simultaneously, rather than consecutively, for example, heart and kidney (3.58 ROR; CI 2.39–5.36), or mental health and musculoskeletal diagnoses (2.38 ROR; CI 1.70–3.32).

Conclusions

Overall, in multimorbidity, the chronology in which diseases develop is not associated with mortality, with few exceptions. For almost all combinations of multimorbidity, diagnoses act synergistically in relation to mortality if diagnosed simultaneously.

A Digital Health Platform for Integrated and Proactive Patient-Centered Multimorbidity Self-management and Care (ProACT): Protocol for an Action Research Proof-of-Concept Trial

Background

Multimorbidity is defined as the presence of two or more chronic diseases and associated comorbidities. There is a need to improve best practices around the provision of well-coordinated, person-centered care for persons with multimorbidities. Present health systems across the European Union (EU) focus on supporting a single-disease framework of care; the primary challenge is to create a patient-centric, integrated care ecosystem to understand and manage multimorbidity. ProACT is a large-scale project funded by the European Commission under the Horizon 2020 programme, that involved the design, development, and evaluation of a digital health platform to improve and advance home-based integrated care, and supported self-management, for older adults (aged ≥65 years) living with multimorbidity.

Objective

This paper describes the trial implementation protocol of a proof-of-concept digital health platform (ProACT) in 2 EU member states (Ireland and Belgium) to support older persons with multimorbidities self-managing at home, supported by their care network (CN).

Methods

Research was conducted across 2 EU member states, Ireland and Belgium. A 12-month action research trial design, divided into 3 evaluation cycles and lasting 3 months each, with a reflective redesign and development phase of 1 month after cycles 1 and 2 was conducted. Participants were 120 (60/120, 50% in Ireland and 60/120, 50% in Belgium) older persons with multimorbidities diagnosed with two or more of the following chronic conditions: diabetes, chronic obstructive pulmonary disease, chronic heart failure, and cardiovascular diseases. With permission from persons with multimorbidities, members of their CN were invited to participate in the study. Persons with multimorbidities were provided with ProACT technologies (tablet, devices, or sensors) to support them in self-managing their conditions. CN members also received access to an app to remotely support their persons with multimorbidity. Qualitative and quantitative feedback and evaluation data from persons with multimorbidity and CN participants were collected across four time points: baseline (T1), at the end of each 3-month action research cycle (T2 and T3), and in a final posttrial interview (T4). Thematic analysis was used to analyze the qualitative interview data. Quantitative data were analyzed via platform use statistics (to assess engagement) and standardized questionnaires (using descriptive and inferential statistics). This study is approved by the ethics committees of Ireland and Belgium.

Results

The trial implementation phase for this 44-month (2016-2019) funded study was April 2018 to June 2019. The trial outcomes are at various stages of publication since 2021.

Conclusions

ProACT aims to co-design and develop a digital intervention with persons with multimorbidities and their CN, incorporating clinical guidelines with the state of the art in human-computer interaction, behavioral science, health psychology, and data analytic methods to deliver a digital health platform to advance self-management of multimorbidity at home, as part of a proactive, integrated model of supported person-centered care.

International Registered Report Identifier (IRRID)

RR1-10.2196/22125

Patient, carer and healthcare professional experiences of complex care quality in multidisciplinary primary healthcare centres: qualitative study with face-to-face, in-depth interviews and focus groups in five French multidisciplinary primary healthcare centres

Objectives

To explore care experiences in multidisciplinary primary healthcare centres from the patients, carers and healthcare professionals perspectives.

Design

This qualitative study used face-to-face, in-depth interviews and focus groups. Patients with multimorbidity monitored by a General Practitioner (GP) and another professional from the health centre were recruited through purposive sampling and included with their carer. They were interviewed together while professionals were interviewed separately. Verbatims were coded with subsequent blind analysis, using an inductive approach, to find aspects and features. The constant comparative method highlighted data consistencies and variations.

Participants

Twenty-six patients, 23 family carers and 57 healthcare professionals.

Setting

Five multidisciplinary primary healthcare centres, in France, between March 2017 and December 2018.

Results

This unique study grouped perspectives into nine core quality of primary care aspects: having accessible, available, and varied care; feeling welcome and enjoying comfortable, well-equipped, and clean premises; having quality medicotechnical care (medical knowledge and technical skills); having a reliable GP; receiving appropriate care from healthcare professionals other than the GP; maintaining an efficient relationship with healthcare professionals; benefiting from organised and coordinated care; being an informed, supported and involved patient; having an informed, supported and involved carer. New areas of interest include the multidisciplinary nature of the centres, appreciation of other professionals within the centre, medicotechnical dimensions of care and the carer’s role in maintaining patient autonomy.

Conclusions

This is the first study to interview patients and carers alongside healthcare professionals. This enhanced knowledge improves understanding of these aspects and can guide implementation of evaluation tools that truly reflect patient and carer needs and enable an efficient experience in terms of quality. To address deficiencies in existing questionnaires, the new perspectives found will be added to former aspects to create a comprehensive quality of primary care evaluation tool.

Trial registration number

NCT02934711, Results.

The Interplay between Housing Environmental Attributes and Design Exposures and Psychoneuroimmunology Profile-An Exploratory Review and Analysis Paper in the Cancer Survivors' Mental Health Morbidity Context

Adult cancer survivors have an increased prevalence of mental health comorbidities and other adverse late-effects interdependent with mental illness outcomes compared with the general population. Coronavirus Disease 2019 (COVID-19) heralds an era of renewed call for actions to identify sustainable modalities to facilitate the constructs of cancer survivorship care and health care delivery through physiological supportive domestic spaces. Building on the concept of therapeutic architecture, psychoneuroimmunology (PNI) indicators-with the central role in low-grade systemic inflammation-are associated with major psychiatric disorders and late effects of post-cancer treatment. Immune disturbances might mediate the effects of environmental determinants on behaviour and mental disorders. Whilst attention is paid to the non-objective measurements for examining the home environmental domains and mental health outcomes, little is gathered about the multidimensional effects on physiological responses. This exploratory review presents a first analysis of how addressing the PNI outcomes serves as a catalyst for therapeutic housing research. We argue the crucial component of housing in supporting the sustainable primary care and public health-based cancer survivorship care model, particularly in the psychopathology context. Ultimately, we illustrate a series of interventions aiming at how housing environmental attributes can trigger PNI profile changes and discuss the potential implications in the non-pharmacological treatment of cancer survivors and patients with mental morbidities.

Measuring Multimorbidity: Selecting the Right Instrument for the Purpose and the Data Source

BACKGROUND

Adults have a higher prevalence of multimorbidity-or having multiple chronic health conditions-than having a single condition in isolation. Researchers, health care providers, and health policymakers find it challenging to decide upon the most appropriate assessment tool from the many available multimorbidity measures.

OBJECTIVE

The objective of this study was to describe a broad range of instruments and data sources available to assess multimorbidity and offer guidance about selecting appropriate measures.

DESIGN

Instruments were reviewed and guidance developed during a special expert workshop sponsored by the National Institutes of Health on September 25-26, 2018.

RESULTS

Workshop participants identified 4 common purposes for multimorbidity measurement as well as the advantages and disadvantages of 5 major data sources: medical records/clinical assessments, administrative claims, public health surveys, patient reports, and electronic health records. Participants surveyed 15 instruments and 2 public health data systems and described characteristics of the measures, validity, and other features that inform tool selection. Guidance on instrument selection includes recommendations to match the purpose of multimorbidity measurement to the measurement approach and instrument, review available data sources, and consider contextual and other related constructs to enhance the overall measurement of multimorbidity.

CONCLUSIONS

The accuracy of multimorbidity measurement can be enhanced with appropriate measurement selection, combining data sources and special considerations for fully capturing multimorbidity burden in underrepresented racial/ethnic populations, children, individuals with multiple Adverse Childhood Events and older adults experiencing functional limitations, and other geriatric syndromes. The increased availability of comprehensive electronic health record systems offers new opportunities not available through other data sources.

Clustering of comorbidities

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

Utilidad del índice de comorbilidad de Charlson en personas ancianas. Concordancia con otros índices de comorbilidad

Objetivo. El objetivo principal de nuestro estudio fue evaluar la utilidad actual del índice de comorbilidad de Charlson (CCI) para predecir la mortalidad en personas mayores y la concordancia entre varios índices. Diseño. Estudio observacional, cohorte concurrente. Emplazamiento. Servicio de Medicina Interna de un hospital terciario, pacientes ambulatorios de un centro de salud y residentes de cuatro hogares de ancianos. Participantes. 375 individuos ≥ 65 años, con supervivencia esperada ≥ 6 meses, sin deterioro cognitivo. Mediciones principales. Se realizaron tres índices: CCI, el índice geriátrico de comorbilidad (GIC) y el índice de Kaplan-Feinstein (KF). A los 12 meses, se registró mortalidad. Los datos se analizaron con IBM SPSS Statistics® versión 23.0. Resultados. Edad media: 81,4 años. El CCI mostró comorbilidad baja-media en el grupo ambulatorio de 65-75 años (43 [75,4%]); moderada-alta más común en hospitalizados (19 [61,3%]) y en hogares de ancianos (5 [62,5%]). Al año fallecieron 59 (16,1%) individuos: con CCI: 10 (6,4%) comorbilidad baja-media y 49 (23,3%) moderada-alta, odds ratio (OR) 3,63 (intervalo de confianza [IC] 95% 1,76-7,51); con KF: 27 (13,3%) baja-media y 32 (19,5%) moderada-alta, OR 1,38 (IC 95% 0,78-2,44), y con GIC: 45 (14,1%) baja-media y 14 (29,2%) moderada-alta, OR 2,47 (IC 95% 1,21-5,06). La concordancia entre CCI-KF fue: 65-75 años: K = 0,62, 76-85 años: K = 0,396, y ≥ 86 años: K = 0,255. La concordancia entre CCI-GIC: 65-75 años: K = 0,202, 76-85 años: K = 0,069, y ≥ 86 años: K = 0,118. Conclusión. El CCI es el mejor predictor de mortalidad después de 1 año de seguimiento. Concordancia considerable entre CCI y KF en los individuos de 65-75 años, en el resto de las franjas etarias la correlación con GIC fue insignificante. Palabras clave: comorbilidad, mortalidad, anciano frágil.

How People with Multimorbidity and Psychosocial Difficulties Experience Support by Rehabilitation Coordinators During Sickness Absence

Purpose

People with multimorbidity face a range of barriers in healthcare, and there is little knowledge about their challenges with regard to return-to-work (RTW). Rehabilitation coordinators, a new function in Swedish healthcare, support people in the RTW process. The present study had two aims: to explore what problems and barriers people with multimorbidity experience during their rehabilitation and RTW process and to explore in which domains the coordinators’ support is perceived to be of importance.

Methods

Interviews were conducted with 12 persons with multimorbidity who had contact with a rehabilitation coordinator during their sickness absence. Thematic analysis was guided by the case-management ecological model; this analysis was revised and adapted to the Swedish context.

Results

The participants experienced problems in all domains of the model, namely: “the healthcare system”, “the labor market and the workplace system”, “the sickness insurance system”, and “the personal system”. Rehabilitation programs that did not accommodate combinations of diseases, social complexities and needs were felt to lead to worse symptoms, thus hindering rather than promoting RTW. An overall finding regarding support by coordinators is that interventions, regardless of domain, were felt to be valuable for people with multimorbidity. The coordinator was perceived to give most support by providing advice about and coordination with healthcare and employers. Sometimes the coordinator gave advice and coordination regarding the Social Insurance Agency, very occasionally the Public Employment Services. The coordinator gave least advice and coordination about social difficulties that hindered rehabilitation and RTW processes.

Conclusion

People with multimorbidity perceive rehabilitation coordinator interventions as important in all domains investigated. Lack of advice and coordination, or rehabilitation programs that were not modified to the complexities of individual’s circumstances, were associated with prolonged sickness absence, worse health, or social risk factors not being recognized.

Chronic disease multimorbidity among the Canadian population: prevalence and associated lifestyle factors

Background

Chronic diseases is increasingly becoming one of the most pressing public health concerns in most part of the world, including the Canadian population. The purpose of this study was to estimate the prevalence of multimorbidity in the general population based on 14 major chronic diseases and examine associations with lifestyle/behavioral factors.

Methods

The data source was the 2015–2016 Canadian Community Health Survey (CCHS). The CCHS is a cross sectional, complex multi-stage survey based on information collected from 109,659 participants aged 12+, covering all provinces and territories. Multimorbidity was defined as the co-occurrence of two or more chronic diseases within a person. Multiple logistic regression was used to examine the key determinants of multimorbidity.

Results

The prevalence of multimorbidity was 33 %. Adjusting for sociodemographic variables, there was an increased odd of multimorbidity for those having a sedentary lifestyle (AOR = 1.06; CI:1.01–1.11) and being obese (AOR = 1.37; CI:1.32–1.43) or overweight (AOR = 2.65; CI: 2.54–2.76). There were two statistically significant interactions, between sex and smoking, and between immigration status and alcohol intake. Smoking was more strongly associated with multimorbidity in females than males. The association between alcohol intake and multimorbidity was also dependent upon immigration status.

Conclusions

Given the high prevalence of multimorbidity among the general Canadian population, policy makers and service providers should give more attention to the behavioral/lifestyle factors which significantly predicted multimorbidity. Policy and program efforts that promote a healthy lifestyle should be a priority.

Chronic diseases in the geriatric population: morbidity and use of primary care services according to risk level

BACKGROUND

Geriatric patients have significant morbidity and greater needs for care and assistance. The objective of this study was to describe the characteristics, morbidity, and use of services in primary care (PC) of patients with chronic diseases older than 65 years according to their risk level assigned by the adjusted morbidity groups (AMG) and to analyse the factors associated with the use of PC services.

METHODS

This was a cross-sectional descriptive observational study. Patients older than 65 years from a healthcare service area, classified as chronically ill by the AMG classification system of the PC electronic medical record of the Community of Madrid, were included. Sociodemographic, clinical-care, and PC service utilization variables were collected. Univariate, bivariate and multivariate analyses were done.

RESULTS

A total of 3292 chronic patients older than 65 years were identified, of whom 1628 (49.5%) were low risk, 1293 (39.3%) were medium risk and 371 (11.3%) were high risk. Their mean age was 78.1 (SD = 8.1) years and 2167 (65.8%) were women. Their mean number of chronic diseases was 3.8 (SD = 2), 89.4% had multimorbidity and 1550 (47.1%) were polymedicated. The mean number of contacts/year with PC was 19.5 (SD = 18.2) [men: 19.4 (SD = 19.8); women: 19.5 (SD = 17.4)]. The mean number of contacts/year in people over 85 years was 25.2 (SD = 19.6); in people 76-85 years old, it was 22.1 (SD = 20.3); and in people 66-75 years old, it was 14.5 (SD = 13.9). The factors associated with greater use of services were age (B coefficient [BC] = 0.3; 95%CI = 0.2-0.4), high risk level (BC = 1.9; 95%CI =0.4-3.2), weight of complexity (BC = 0.7; 95%CI = 0.5-0.8), and ≥ 4 chronic diseases (BC = 0.7; 95%CI = 0.3-1.1).

CONCLUSIONS

In the geriatric population, we found a high number of patients with chronic diseases and there were three levels of risk by AMG with differences in characteristics, morbidity, and use of PC services. The greatest use of services was by patients with older age, high risk level, greater weight of complexity and ≥ 4 chronic diseases. Further research is needed to develop an intervention model more adapted to the reality of the geriatric population based on risk levels by AMG.

Implementing the US Department of Health and Human Services definition of multimorbidity: a comparison between billing codes and medical record review in a population-based sample of persons 4084 years old

OBJECTIVE

To assess the validity of the US Department of Health and Human Services (DHHS) definition of multimorbidity using International Classification of Diseases, ninth edition (ICD-9) codes from administrative data.

DESIGN

Cross-sectional comparison of two ICD-9 billing code algorithms to data abstracted from medical records.

SETTING

Olmsted County, Minnesota, USA.

PARTICIPANTS

An age-stratified and sex-stratified random sample of 1509 persons ages 40-84 years old residing in Olmsted County on 31 December 2010.

STUDY MEASURES

Seventeen chronic conditions identified by the US DHHS as important in studies of multimorbidity were identified through medical record review of each participant between 2006 and 2010. ICD-9 administrative billing codes corresponding to the 17 conditions were extracted using the Rochester Epidemiology Project records-linkage system. Persons were classified as having each condition using two algorithms: at least one code or at least two codes separated by more than 30 days. We compared the ICD-9 code algorithms with the diagnoses obtained through medical record review to identify persons with multimorbidity (defined as ≥2, ≥3 or ≥4 chronic conditions).

RESULTS

Use of a single code to define each of the 17 chronic conditions resulted in sensitivity and positive predictive values (PPV) ≥70%, and in specificity and negative predictive values (NPV) ≥70% for identifying multimorbidity in the overall study population. PPV and sensitivity were highest in persons 65-84 years of age, whereas NPV and specificity were highest in persons 40-64 years. The results varied by condition, and by age and sex. The use of at least two codes reduced sensitivity, but increased specificity.

CONCLUSIONS

The use of a single code to identify each of the 17 chronic conditions may be a simple and valid method to identify persons who meet the DHHS definition of multimorbidity in populations with similar demographic, socioeconomic, and health care characteristics.

Trends of multimorbidity in 15 European countries: a population-based study in community-dwelling adults aged 50 and over

BACKGROUND

The objective of this work was to analyse the prevalence trends of multimorbidity among European community-dwelling adults.

METHODS

A temporal series study based on waves 1, 2, 4, 5, 6 and 7 of the Survey of Health, Ageing and Retirement in Europe (SHARE) was conducted, and community-dwelling participants aged 50+ (n = 274,614) from 15 European countries were selected for the period 2004-2017. Prevalence, adjusted by age, Average Annual Percentage Change (APC) and 95% confidence interval (95% CI) were all calculated. Trend analyses were realised by period, age groups and groups of diseases.

RESULTS

The results showed a large variability in the prevalence of multimorbidity in adults aged 50 and over among European countries. Increase in the prevalence of multimorbidity in the countries of central Europe (Austria, Belgium, Czech Republic, France, Germany and Switzerland) and Spain in both sexes, and in the Netherlands among men. Stability was observed in northern and eastern European countries. Musculoskeletal and neurodegenerative groups showed more significant changes in the trend analyses.

CONCLUSIONS

This information can be useful for policy makers when planning health promotion and prevention policies addressing modifiable risk factors in health.

Hearing Screening for Residents in Long-Term Care Homes Who Live with Dementia: A Scoping Review

BACKGROUND

Hearing loss is highly prevalent in older adults, particularly among those living with dementia and residing in long-term care homes (LTCHs). Sensory declines can have deleterious effects on functioning and contribute to frailty, but the hearing needs of residents are often unrecognized or unaddressed.

OBJECTIVE

To identify valid and reliable screening measures that are effective for the identification of hearing loss and are suitable for use by nursing staff providing care to residents with dementia in LTCHs.

METHODS

Electronic databases (Embase, Medline, PsycINFO, CENTRAL, and CINAHL) were searched using comprehensive search strategies, and a stepwise approach based on Arksey & O'Malley's scoping review and appraisal process was followed.

RESULTS

There were 193 scientific papers included in the review. Pure-tone audiometry was the most frequently reported measure to test hearing in older adults living with dementia. However, measures including self- or other-reports and questionnaires, review of medical records, otoscopy, and the whisper test were found to be most suitable for use by nurses working with older adults living with dementia in LTCHs.

CONCLUSION

Although frequently used, the suitability of pure-tone audiometry for use by nursing staff in LTCHs is limited, as standardized audiometry presents challenges for many residents, and specific training is needed to successfully adapt test administration procedures and interpret results. The whisper test was considered to be more suitable for use by staff in LTCH; however, it yields a limited characterization of hearing loss. There remains an urgent need to develop new approaches to screen hearing in LTCHs.

Laying the foundation for an International Classification of Functioning, Disability and Health Core Set for community-dwelling elderly adults in primary care: the clinical perspective identified in a cross-sectional study

OBJECTIVES

Having more information about the biopsychosocial functioning of their geriatric patients might help physicians better balance medical interventions according to patients' needs. For this reason, we aimed to develop an easy-to-handle International Classification of Functioning, Disability and Health (ICF) Core Set for community-dwelling geriatric patients aged 75 and older in primary care. In this empirical study, we describe the functioning and health of community-dwelling patients aged 75 and older in primary care in Germany and identify the most common problems encountered by these individuals when using the ICF.

DESIGN

In this exploratory, cross-sectional study, a health professional conducted semi-structured interviews.

SETTING

Community-dwelling older adults aged 75 and older in Germany.

PARTICIPANTS

65 participants (mean age=80.2, SD=3.6).

OUTCOME MEASURES

Extended ICF Checklist V.2.1a, patients prioritised chapters of the 'activities and participation' component.

RESULTS

The three most common impairments for 'body functions' were visual system functions (ICF-code b210; 89%), blood pressure functions (b420; 80%) and sensations associated with hearing and vestibular functions (b240; 59%). For 'body structures', they were eyes, ears and related structures (s2; 81%), structure of mouth (s320; 74%) and structures related to the digestive, metabolic and endocrine systems (s5; 49%). For the 'activities and participation' component, adequate aids compensated for activity limitations to a certain degree. Still, after having adequate aids, the category in which the participants had the most difficulty was walking (d450; 35%). Participants rated the 'mobility' chapter as the most important of all chapters. 'Environmental factors' were facilitators of participants' functioning.

CONCLUSIONS

This empirical study provides a list of ICF categories relevant to older adults from the clinical perspective. Along with lists from the other three preparatory studies, it will form the basis for the development of an ICF Core Set for community-dwelling older adults in primary care.

TRIAL REGISTRATION DETAILS

The trial is registered in ClinicalTrials.gov (NCT03384732).