Global burden of 288 causes of death and life expectancy decomposition in 204 countries and territories and 811 subnational locations, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Regular, detailed reporting on population health by underlying cause of death is fundamental for public health decision making. Cause-specific estimates of mortality and the subsequent effects on life expectancy worldwide are valuable metrics to gauge progress in reducing mortality rates. These estimates are particularly important following large-scale mortality spikes, such as the COVID-19 pandemic. When systematically analysed, mortality rates and life expectancy allow comparisons of the consequences of causes of death globally and over time, providing a nuanced understanding of the effect of these causes on global populations.

METHODS

The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 cause-of-death analysis estimated mortality and years of life lost (YLLs) from 288 causes of death by age-sex-location-year in 204 countries and territories and 811 subnational locations for each year from 1990 until 2021. The analysis used 56 604 data sources, including data from vital registration and verbal autopsy as well as surveys, censuses, surveillance systems, and cancer registries, among others. As with previous GBD rounds, cause-specific death rates for most causes were estimated using the Cause of Death Ensemble model-a modelling tool developed for GBD to assess the out-of-sample predictive validity of different statistical models and covariate permutations and combine those results to produce cause-specific mortality estimates-with alternative strategies adapted to model causes with insufficient data, substantial changes in reporting over the study period, or unusual epidemiology. YLLs were computed as the product of the number of deaths for each cause-age-sex-location-year and the standard life expectancy at each age. As part of the modelling process, uncertainty intervals (UIs) were generated using the 2·5th and 97·5th percentiles from a 1000-draw distribution for each metric. We decomposed life expectancy by cause of death, location, and year to show cause-specific effects on life expectancy from 1990 to 2021. We also used the coefficient of variation and the fraction of population affected by 90% of deaths to highlight concentrations of mortality. Findings are reported in counts and age-standardised rates. Methodological improvements for cause-of-death estimates in GBD 2021 include the expansion of under-5-years age group to include four new age groups, enhanced methods to account for stochastic variation of sparse data, and the inclusion of COVID-19 and other pandemic-related mortality-which includes excess mortality associated with the pandemic, excluding COVID-19, lower respiratory infections, measles, malaria, and pertussis. For this analysis, 199 new country-years of vital registration cause-of-death data, 5 country-years of surveillance data, 21 country-years of verbal autopsy data, and 94 country-years of other data types were added to those used in previous GBD rounds.

FINDINGS

The leading causes of age-standardised deaths globally were the same in 2019 as they were in 1990; in descending order, these were, ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and lower respiratory infections. In 2021, however, COVID-19 replaced stroke as the second-leading age-standardised cause of death, with 94·0 deaths (95% UI 89·2-100·0) per 100 000 population. The COVID-19 pandemic shifted the rankings of the leading five causes, lowering stroke to the third-leading and chronic obstructive pulmonary disease to the fourth-leading position. In 2021, the highest age-standardised death rates from COVID-19 occurred in sub-Saharan Africa (271·0 deaths [250·1-290·7] per 100 000 population) and Latin America and the Caribbean (195·4 deaths [182·1-211·4] per 100 000 population). The lowest age-standardised death rates from COVID-19 were in the high-income super-region (48·1 deaths [47·4-48·8] per 100 000 population) and southeast Asia, east Asia, and Oceania (23·2 deaths [16·3-37·2] per 100 000 population). Globally, life expectancy steadily improved between 1990 and 2019 for 18 of the 22 investigated causes. Decomposition of global and regional life expectancy showed the positive effect that reductions in deaths from enteric infections, lower respiratory infections, stroke, and neonatal deaths, among others have contributed to improved survival over the study period. However, a net reduction of 1·6 years occurred in global life expectancy between 2019 and 2021, primarily due to increased death rates from COVID-19 and other pandemic-related mortality. Life expectancy was highly variable between super-regions over the study period, with southeast Asia, east Asia, and Oceania gaining 8·3 years (6·7-9·9) overall, while having the smallest reduction in life expectancy due to COVID-19 (0·4 years). The largest reduction in life expectancy due to COVID-19 occurred in Latin America and the Caribbean (3·6 years). Additionally, 53 of the 288 causes of death were highly concentrated in locations with less than 50% of the global population as of 2021, and these causes of death became progressively more concentrated since 1990, when only 44 causes showed this pattern. The concentration phenomenon is discussed heuristically with respect to enteric and lower respiratory infections, malaria, HIV/AIDS, neonatal disorders, tuberculosis, and measles.

INTERPRETATION

Long-standing gains in life expectancy and reductions in many of the leading causes of death have been disrupted by the COVID-19 pandemic, the adverse effects of which were spread unevenly among populations. Despite the pandemic, there has been continued progress in combatting several notable causes of death, leading to improved global life expectancy over the study period. Each of the seven GBD super-regions showed an overall improvement from 1990 and 2021, obscuring the negative effect in the years of the pandemic. Additionally, our findings regarding regional variation in causes of death driving increases in life expectancy hold clear policy utility. Analyses of shifting mortality trends reveal that several causes, once widespread globally, are now increasingly concentrated geographically. These changes in mortality concentration, alongside further investigation of changing risks, interventions, and relevant policy, present an important opportunity to deepen our understanding of mortality-reduction strategies. Examining patterns in mortality concentration might reveal areas where successful public health interventions have been implemented. Translating these successes to locations where certain causes of death remain entrenched can inform policies that work to improve life expectancy for people everywhere.

FUNDING

Bill & Melinda Gates Foundation.

Development and validation of new multimorbidity-weighted index for ICD-10-coded electronic health record and claims data: an observational study

OBJECTIVE

Map multimorbidity-weighted index (MWI) conditions to International Classification of Diseases, 10th Revision (ICD-10), expand the conditions and codes to develop a new ICD-10-coded MWI (MWI-ICD10) and updated MWI-ICD9, and assess their consistency.

DESIGN

Population-based retrospective cohort.

SETTING

Large medical centre between 2013 and 2017.

PARTICIPANTS

Adults ≥18 years old with encounters in each of 4 years (2013, 2014, 2016, 2017).

MAIN OUTCOME MEASURES

MWI conditions mapped to ICD-10 codes, and additional conditions and codes added to produce a new MWI-ICD10 and updated MWI-ICD9. We compared the prevalence of ICD-coded MWI conditions within the ICD-9 era (2013-2014), within the ICD-10 era (2016-2017) and across the ICD-9-ICD-10 transition in 2015 (washout period) among adults present in both sets of comparison years. We computed the prevalence and change in prevalence of conditions when using MWI-ICD10 versus MWI-ICD9.

RESULTS

88 175 adults met inclusion criteria. Participants were 60.8% female, 50.5% white, with mean age 54.7±17.3 years and baseline MWI-ICD9 4.47±6.02 (range 0-64.33). Of 94 conditions, 65 had <1% difference across the ICD-9-ICD-10 transition and similar minimal changes within ICD coding eras.

CONCLUSIONS

MWI-ICD10 captured the prevalence of chronic conditions nearly identically to that of the validated MWI-ICD9, along with notable but explicable changes across the ICD-10 transition. This new comprehensive person-centred index enables quantification of cumulative disease burden and physical functioning in adults as a clinically meaningful measure of multimorbidity in electronic health record and claims data.

Readmissions and postdischarge mortality by race and ethnicity among Medicare beneficiaries with multimorbidity

BACKGROUND

Disparities in readmission risk and reasons they might exist among diverse complex patients with multimorbidity, disability, and unmet social needs have not been clearly established. These characteristics may be underestimated in claims-based studies where individual-level data are limited. We sought to examine the risk of readmissions and postdischarge mortality by race and ethnicity after rigorous adjustment for multimorbidity, physical functioning, and sociodemographic and lifestyle characteristics.

METHODS

We used Health and Retirement Study (HRS) data linked to Medicare claims. To obtain ICD-9-CM diagnostic codes to compute the ICD-coded multimorbidity-weighted index (MWI-ICD) we used Medicare Parts A and B (inpatient, outpatient, carrier) files between 1991-2015. Participants must have had at least one hospitalization between January 1, 2000 and September 30, 2015 and continuous enrollment in fee-for-service Medicare Part A 1-year prior to hospitalization. We used multivariable logistic regression to assess the association of MWI-ICD with 30-day readmissions and mortality 1-year postdischarge. Using HRS data, we adjusted for age, sex, BMI, smoking, physical activity, education, household net worth, and living arrangement/marital status, and examined for effect modification by race and ethnicity.

RESULTS

The final sample of 10,737 participants had mean ± SD age 75.9 ± 8.7 years. Hispanic adults had the highest mean MWI-ICD (16.4 ± 10.1), followed by similar values for White (mean 14.8 ± 8.9) and Black (14.7 ± 8.9) adults. MWI-ICD was associated with a higher odds of readmission, and there was no significant effect modification by race and ethnicity. For postdischarge mortality, a 1-point increase MWI-ICD was associated with a 3% higher odds of mortality (OR = 1.03, 95% CI: 1.03-1.04), which did not significantly differ by race and ethnicity.

CONCLUSIONS

Multimorbidity was associated with a monotonic increased odds of 30-day readmission and 1-year postdischarge mortality across all race and ethnicity groups. There was no significant difference in readmission or mortality risk by race and ethnicity after robust adjustment.

Multimorbidity, 30-Day Readmissions, and Postdischarge Mortality Among Medicare Beneficiaries Using a New ICD-Coded Multimorbidity-Weighted Index

BACKGROUND

Medically complex, disabled adults have high 30-day readmission rates. However, physical functioning is not routinely included in risk-adjustment models. We examined the association between multimorbidity with readmissions and mortality using a physical functioning weighted International Classification of Diseases (ICD)-coded multimorbidity-weighted index (MWI-ICD) representing 84 conditions.

METHODS

We included Medicare beneficiaries with ≥1 hospitalization 2000-2015 who participated in a Health and Retirement Study interview before admission. We computed MWI-ICD by summing physical functioning weighted conditions from Medicare claims. We examined 30-, 90-, and 365-day postdischarge mortality using multivariable logistic regression and length of stay through zero-inflated negative binomials. Models adjusted for age, sex, race/ethnicity, body mass index, smoking status, physical activity, education, net worth, and marital status/living arrangement.

RESULTS

The final sample of 10 737 participants had mean ± standard deviation (SD) age 75.9 ± 8.7 years, MWI-ICD 14.9 ± 9.0, and 20% had a 30-day readmission. Adults in the highest versus lowest quartile MWI-ICD had 92% increased odds of 30-day readmission (odds ratio [OR] = 1.92, 95% confidence interval [CI]: 1.65-2.22). A 1-point increase in MWI-ICD was associated with 24% increased odds of 30-day readmission (OR = 1.24, 95% CI: 1.18-1.31). A 1-point increase in MWI-ICD was associated with 32% increased odds of death within 365-day postdischarge (OR = 1.32, 95% CI: 1.25-1.40). Readmitted participants with the highest versus lowest quartile MWI-ICD had 37% increased number of expected hospitalized days (incidence rate ratio = 1.37, 95% CI: 1.17-1.59).

CONCLUSION

Among Medicare beneficiaries, multimorbidity using MWI-ICD is associated with an increased risk of readmissions, mortality, and longer length of stay. MWI-ICD appears to be a valid measure of multimorbidity that embeds physical functioning and presents an opportunity to incorporate functional status into claims-based risk-adjustment models.

Multimorbidity and long-term disability and physical functioning decline in middle-aged and older Americans: an observational study

BACKGROUND

Multimorbidity is highly prevalent and associated with several adverse health outcomes, including functional limitations. While maintaining physical functioning is relevant for all adults, identifying those with multimorbidity at risk for faster rates of physical functioning decline may help to target interventions to delay the onset and progression of disability. We quantified the association of multimorbidity with rates of long-term disability and objective physical functioning decline.

METHODS

In the Health and Retirement Study, we computed the Multimorbidity-Weighted Index (MWI) by assigning previously validated weights (based on physical functioning) to each chronic condition. We used an adjusted negative binomial regression to assess the association of MWI with disability (measured by basic and instrumental activities of daily living [ADLs, IADLs]) over 16 years, and linear mixed effects models to assess the association of MWI with gait speed and grip strength over 8 years.

RESULTS

Among 16,616 participants (mean age 67.3, SD 9.7 years; 57.8% women), each additional MWI point was associated with a 10% increase in incidence rate of disability (IRR: 1.10; 95%CI: 1.09, 1.10). In 2,748 participants with data on gait speed and grip strength, each additional MWI point was associated with a decline in gait speed of 0.004 m/s (95%CI: -0.006, -0.001). The association with grip strength was not statistically significant (-0.01 kg, 95%CI: -0.73, 0.04). The rate of decline increased with time for all outcomes, with a significant interaction between time and MWI for disability progression only.

CONCLUSION

Multimorbidity, as weighted on physical functioning, was associated with long-term disability, including faster rates of disability progression, and decline in gait speed. Given the importance of maintaining physical functioning and preserving functional independence, MWI is a readily available tool that can help identify adults to target early on for interventions.

Comparing the association between multiple chronic conditions, multimorbidity, frailty, and survival among older patients with cancer

INTRODUCTION

The high prevalence of multiple chronic conditions (MCC), multimorbidity, and frailty may affect treatment and outcomes for older adults with cancer. The goal of this study was to use three conceptually distinct measures of morbidity to examine the association between these measures and mortality.

MATERIALS AND METHODS

Using Medicare claims data linked with the 2012-2016 Ohio Cancer Incidence Surveillance System we identified older adults with incident primary cancer sites of breast, colorectal, lung, or prostate (n = 29,140). We used claims data to identify their Elixhauser comorbidities, Multimorbidity-Weighted Index (MWI), and Claims Frailty Index (CFI) as measures of MCC, multimorbidity, and frailty, respectively. We used Cox proportional hazard models to examine the association between these measures and survival time since diagnosis.

RESULTS

Lung cancer patients had the highest levels of MCC, multimorbidity, and frailty. There was a positive association between all three measures and a greater hazard of death after adjusting for age, sex (colorectal and lung only), and stage. Breast cancer patients with 5+ comorbidities had an adjusted hazard ratio (aHR) of 1.63 (95% confidence interval [CI]: 1.38, 1.93), and those with mild frailty had an aHR of 3.38 (95% CI; 2.12, 5.41). The C statistics for breast cancer were 0.79, 0.78, and 0.79 for the MCC, MWI, and CFI respectively. Similarly, lung cancer patients who were moderately or severely frail had an aHR of 1.82 (95% CI: 1.53, 2.18) while prostate cancer patients had an aHR of 3.39 (95% CI: 2.12, 5.41) and colorectal cancer patients had an aHR of 4.51 (95% CI: 3.23, 6.29). Model performance was nearly identical across the MCC, multimorbidity, and frailty models within cancer type. The models performed best for prostate and breast cancer, and notably worse for lung cancer. The frailty models showed the greatest separation in unadjusted survival curves.

DISCUSSION

The MCC, multimorbidity, and frailty indices performed similarly well in predicting mortality among a large cohort of older cancer patients. However, there were notable differences by cancer type. This work highlights that although model performance is similar, frailty may serve as a clearer indicator in risk stratification of geriatric oncology patients than simple MCCs or multimorbidity.

Association of multimorbidity patterns with incident disability and recovery of independence among middle-aged and older adults

OBJECTIVE

to identify multimorbidity patterns among middle-aged and older adults in China and examine how these patterns are associated with incident disability and recovery of independence.

METHODS

data were from The China Health and Retirement Longitudinal Study. We included 14,613 persons aged ≥45 years. Latent class analysis (LCA) was conducted to identify multimorbidity patterns with clinical meaningfulness. Multinomial logistic models were used to determine the adjusted association between multimorbidity patterns and incident disability and recovery of independence.

RESULTS

we identified four multimorbidity patterns: 'low morbidity' (67.91% of the sample), 'pulmonary-digestive-rheumatic' (17.28%), 'cardiovascular-metabolic-neuro' (10.77%) and 'high morbidity' (4.04%). Compared to the 'low morbidity' group, 'high morbidity' (OR = 2.63, 95% CI = 1.97-3.51), 'pulmonary-digestive-rheumatic' (OR = 1.89, 95% CI = 1.63-2.21) and 'cardiovascular-metabolic-neuro' pattern (OR = 1.61, 95% CI = 1.31-1.97) had higher odds of incident disability in adjusted multinomial logistic models. The 'cardiovascular-metabolic-neuro' (OR = 0.60, 95% CI = 0.44-0.81), 'high morbidity' (OR = 0.68, 95% CI = 0.47-0.98) and 'pulmonary-digestive-rheumatic' group (OR = 0.75, 95% CI = 0.60-0.95) had lower odds of recovery from disability than the 'low morbidity' group. Among people without disability, the 'cardiovascular-endocrine-neuro' pattern was associated with the highest 2-year mortality (OR = 2.42, 95% CI = 1.56-3.72).

CONCLUSIONS

multimorbidity is complex and heterogeneous, but our study demonstrates that clinically meaningful patterns can be obtained using LCA. We highlight four multimorbidity patterns with differential effects on incident disability and recovery from disability. These studies suggest that targeted prevention and treatment approaches are needed for people with multimorbidity.

Prediction of Future Health Care Utilization Through Note-extracted Psychosocial Factors

BACKGROUND

Persons with multimorbidity (≥2 chronic conditions) face an increased risk of poor health outcomes, especially as they age. Psychosocial factors such as social isolation, chronic stress, housing insecurity, and financial insecurity have been shown to exacerbate these outcomes, but are not routinely assessed during the clinical encounter. Our objective was to extract these concepts from chart notes using natural language processing and predict their impact on health care utilization for patients with multimorbidity.

METHODS

A cohort study to predict the 1-year likelihood of hospitalizations and emergency department visits for patients 65+ with multimorbidity with and without psychosocial factors. Psychosocial factors were extracted from narrative notes; all other covariates were extracted from electronic health record data from a large academic medical center using validated algorithms and concept sets. Logistic regression was performed to predict the likelihood of hospitalization and emergency department visit in the next year.

RESULTS

In all, 76,479 patients were eligible; the majority were White (89%), 54% were female, with mean age 73. Those with psychosocial factors were older, had higher baseline utilization, and more chronic illnesses. The 4 psychosocial factors all independently predicted future utilization (odds ratio=1.27-2.77, C -statistic=0.63). Accounting for demographics, specific conditions, and previous utilization, 3 of 4 of the extracted factors remained predictive (odds ratio=1.13-1.86) for future utilization. Compared with models with no psychosocial factors, they had improved discrimination. Individual predictions were mixed, with social isolation predicting depression and morbidity; stress predicting atherosclerotic cardiovascular disease onset; and housing insecurity predicting substance use disorder morbidity.

DISCUSSION

Psychosocial factors are known to have adverse health impacts, but are rarely measured; using natural language processing, we extracted factors that identified a higher risk segment of older adults with multimorbidity. Combining these extraction techniques with other measures of social determinants may help catalyze population health efforts to address psychosocial factors to mitigate their health impacts.

Multimorbidity and Inpatient Utilization Among Older Adults with Opioid Use Disorder in New York City

BACKGROUND

Nationally, there is a sharp increase in older adults with opioid use disorder (OUD). However, we know little of the acute healthcare utilization patterns and medical comorbidities among this population.

OBJECTIVE

This study describes the prevalence of chronic conditions, patterns of inpatient utilization, and correlates of high inpatient utilization among older adults with OUD in New York City (NYC).

DESIGN

Retrospective longitudinal cohort study.

PARTICIPANTS

Patients aged ≥55 with OUD hospitalized in NYC in 2012 identified using data from New York State's Statewide Planning and Research Cooperative System (SPARCS).

MAIN MEASURES

The prevalence of comorbid substance use diagnoses, chronic medical disease, and mental illness was measured using admission diagnoses from the index hospitalization. We calculated the ICD-Coded Multimorbidity-Weighted Index (MWI-ICD) for each patient to measure multimorbidity. We followed the cohort through September 30, 2015 and the outcome was the number of rehospitalizations for inpatient services in NYC. We compared patient-level factors between patients with the highest use of inpatient services (≥7 rehospitalizations) during the study period to low utilizers. We used multiple logistic regression to examine possible correlates of high inpatient utilization.

KEY RESULTS

Of 3669 adults aged ≥55 with OUD with a hospitalization in 2012, 76.4% (n=2803) had a subsequent hospitalization and accounted for a total of 22,801 rehospitalizations during the study period. A total of 24.7% of the cohort (n=906) were considered high utilizers and had a higher prevalence of alcohol and cocaine-related diagnoses, congestive heart failure, diabetes, schizophrenia, and chronic obstructive pulmonary disease. Multivariable predictors of high utilization included being a Medicaid beneficiary (adjusted odds ratio [aOR]=1.70, 95% confidence interval [CI]=1.37-2.11), alcohol-related diagnoses (aOR=1.43, 95% CI: 1.21-1.69), and increasing comorbidity measured by MWI-ICD (highest MWI-ICD quartile: aOR=1.98, 95% CI=1.59-2.48).

CONCLUSIONS

Among older adults with OUD admitted to the hospital, multimorbidity is strongly associated with high inpatient utilization.

Multimorbidity and Social Participation Is Moderated by Purpose in Life and Life Satisfaction

OBJECTIVES

We examined the association between multimorbidity and social participation and whether purpose in life and life satisfaction moderate this relationship.

METHODS

Participants were 12,825 Health and Retirement Study adults. We used multiple linear regression to examine the association between a cumulative-updated multimorbidity-weighted index (MWI) and social participation.

RESULTS

Among adults with average purpose in life or life satisfaction, MWI was associated with lower social participation. For those with above average purpose in life, each 1-point increase in MWI was associated with a 0.11-point (95% confidence interval [CI]: [0.07, 0.14]) better social participation score. Participants with above average life satisfaction experienced a 0.04-point (95% CI: [0.02, 0.07]) better social participation score with each 1-point increase in MWI.

DISCUSSION

Multimorbidity was associated with worse social participation, but this was reversed by above average purpose in life and life satisfaction. Interventions that improve well-being should be assessed to enhance social participation among older adults with any degree of multimorbidity.

Innovative Strategies to Facilitate Patient-Centered Research in Multiple Chronic Conditions

Multiple chronic conditions (MCC) are one of today’s most pressing healthcare concerns, affecting 25% of all Americans and 75% of older Americans. Clinical care for individuals with MCC is often complex, condition-centric, and poorly coordinated across multiple specialties and healthcare services. There is an urgent need for innovative patient-centered research and intervention development to address the unique needs of the growing population of individuals with MCC. In this commentary, we describe innovative methods and strategies to conduct patient-centered MCC research guided by the goals and objectives in the Department of Health and Human Services MCC Strategic Framework. We describe methods to (1) increase the external validity of trials for individuals with MCC; (2) study MCC epidemiology; (3) engage clinicians, communities, and patients into MCC research; and (4) address health equity to eliminate disparities.

Roles of Postdiagnosis Accumulation of Morbidities and Lifestyle Changes in Excess Total and Cause-Specific Mortality Risk in Rheumatoid Arthritis

OBJECTIVE

To elucidate how postdiagnosis multimorbidity and lifestyle changes contribute to the excess mortality of rheumatoid arthritis (RA).

METHODS

We performed a matched cohort study among women in the Nurses' Health Study (1976-2018). We identified women with incident RA and matched each by age and year to 10 non-RA comparators at the RA diagnosis index date. Specific causes of death were ascertained via death certificates and medical record review. Lifestyle and morbidity factors were reported biennially; 61 chronic conditions were combined into the Multimorbidity Weighted Index (MWI). After adjusting for baseline confounders, we used inverse probability weighting analysis to examine the mediating influence of postindex MWI scores and lifestyle factors on total, cardiovascular, and respiratory mortality, comparing women with RA to their matched comparators.

RESULTS

We identified 1,007 patients with incident RA and matched them to 10,070 non-RA comparators. After adjusting for preindex confounders, we found that hazard ratios (HRs) and 95% confidence intervals (95% CIs) were higher for total mortality (HR 1.46 [95% CI 1.32, 1.62]), as well as cardiovascular (HR 1.54 [95% CI 1.22, 1.94]) and respiratory (HR 2.75 [95% CI 2.05, 3.71]) mortality in patients with RA compared to non-RA comparators. Adjusting for postindex lifestyle factors (physical activity, body mass index, diet, smoking) attenuated but did not substantially account for this excess RA mortality. After additional adjustment for postindex MWI scores, patients with RA had HRs of 1.18 (95% CI 1.05, 1.32) for total, 1.19 (95% CI 0.94, 1.51) for cardiovascular, and 1.93 (95% CI 1.42, 2.62) for respiratory mortality.

CONCLUSION

We found that MWI scores substantially accounted for the excess total and cardiovascular mortality among women with RA. This finding underscores the importance of monitoring for the total disease burden as a whole in monitoring patients with RA.

Focus and features of prescribing indications spanning multiple chronic conditions in older adults: A narrative review

Background:

Inappropriate prescribing is frequent in older adults and associated with adverse outcomes. Prescribing indications aim to optimize prescribing, but little is known about the focus and features of prescribing indications for the most common chronic conditions in older adults. Understanding the conditions, medications, and issues addressed (e.g., patient perspective, drug-disease interaction, adverse drug event) in current prescribing indications may help to identify missing indications and develop standardized measures to improve prescribing quality.

Methods:

We searched Ovid/MEDLINE and EMBASE for articles published between 2015 and 2020 reporting prescribing indications for older adults. Prescribing indication included 1) prescribing “criteria,” or statements that guide prescribing action, and 2) prescribing “measures,” or prescribing actions observed in a population. We categorized their focus by conditions, medications and issues addressed, as well as level of evidence provided.

Results:

Among 16 sets of prescribing indications, we identified 748 criteria and 47 measures. The most common addressed medications were antihypertensives, analgesics/antirheumatics, and antiplatelets/anticoagulants. The most frequently addressed issues were drug-disease interaction, adverse drug event, administration, better therapeutic alternative, and (co-)prescription omission (20.8–36.1%). Age/functioning, drug-drug interaction, monitoring, and efficacy/safety ratio were found in only 9.9–16.5% of indications. Indications rarely focused on the patient perspective or issues with multiple providers.

Conclusion:

Most prescribing indications for chronic conditions in older patients are criteria rather than measures. Indications accounting for patient perspective and multiple providers are limited. The gaps identified in this review may help improve the development of prescribing measures for older adults and ultimately improve quality of care.

Sex Differences in Autoimmune Multimorbidity in Type 1 Diabetes Mellitus and the Risk of Cardiovascular and Renal Disease: A Longitudinal Study in the United States, 2001-2017

Background: Autoimmune diseases are usually more prevalent in women. The risks of cardiovascular and renal disease in those with multiple autoimmune diseases have not been fully described. Materials and Methods: Using a national database from a large health insurer in the United States (years 2001-2017) containing ∼75 million members, we calculated age- and sex-specific co-prevalence of 12 autoimmune disorders for individuals with type 1 diabetes. We then evaluated whether concomitant autoimmune diseases were associated with renal failure, ischemic stroke, and myocardial infarction. Results: Of the 179,248 people diagnosed with type 1 diabetes, 1 in 4 had a concomitant autoimmune disease (27.03%; 95% confidence interval [CI] = 26.83%-27.24%), with hypothyroidism, rheumatoid arthritis, and celiac disease being the most common. The prevalence of autoimmune disease was 1.9 times greater in female than male patients (p < 0.001). In female patients with type 1 diabetes, one in three had another autoimmune disease (35.62%; 95% CI = 35.30%-35.94%) compared with one in five male patients (19.17%; 95% CI = 18.92%-19.42%). The risk of renal failure, ischemic stroke, and myocardial infarction increased with a greater number of concomitant autoimmune diseases (p < 0.001, test for trend for both female and male patients). Patients with type 1 diabetes who had multiple sclerosis or myasthenia gravis experienced an approximate threefold increase in risk of ischemic stroke (odds ratio [OR] = 3.57, OR = 3.22, respectively). Patients with type 1 diabetes and Addison's disease had a threefold increased risk of renal failure. Conclusions: Patients with type 1 diabetes, particularly women, frequently have coexisting autoimmune diseases that are associated with higher rates of renal failure, ischemic stroke, and myocardial infarction. Additional study is warranted, as are preventive efforts in this high-risk population.

Evaluating a Widely Implemented Proprietary Deterioration Index Model Among Hospitalized COVID-19 Patients

INTRODUCTION

The Epic Deterioration Index (EDI) is a proprietary prediction model implemented in over 100 U.S. hospitals that was widely used to support medical decision-making during the COVID-19 pandemic. The EDI has not been independently evaluated, and other proprietary models have been shown to be biased against vulnerable populations.

METHODS

We studied adult patients admitted with COVID-19 to non-ICU care at a large academic medical center from March 9 through May 20, 2020. We used the EDI, calculated at 15-minute intervals, to predict a composite outcome of ICU-level care, mechanical ventilation, or in-hospital death. In a subset of patients hospitalized for at least 48 hours, we also evaluated the ability of the EDI to identify patients at low risk of experiencing this composite outcome during their remaining hospitalization.

RESULTS

Among 392 COVID-19 hospitalizations meeting inclusion criteria, 103 (26%) met the composite outcome. Median age of the cohort was 64 (IQR 53-75) with 168 (43%) African Americans and 169 (43%) women. Area under the receiver-operating-characteristic curve (AUC) of the EDI was 0.79 (95% CI 0.74-0.84). EDI predictions did not differ by race or sex. When exploring clinically-relevant thresholds of the EDI, we found patients who met or exceeded an EDI of 68.8 made up 14% of the study cohort and had a 74% probability of experiencing the composite outcome during their hospitalization with a median lead time of 24 hours from when this threshold was first exceeded. Among the 286 patients hospitalized for at least 48 hours who had not experienced the composite outcome, 14 (13%) never exceeded an EDI of 37.9, with a negative predictive value of 90% and a sensitivity above this threshold of 91%.

CONCLUSION

We found the EDI identifies small subsets of high- and low-risk COVID-19 patients with fair discrimination. We did not find evidence of bias by race or sex. These findings highlight the importance of independent evaluation of proprietary models before widespread operational use among COVID-19 patients.

Comprehensive review of ICD-9 code accuracies to measure multimorbidity in administrative data

Background

Quantifying the burden of multimorbidity for healthcare research using administrative data has been constrained. Existing measures incompletely capture chronic conditions of relevance and are narrowly focused on risk-adjustment for mortality, healthcare cost or utilization. Moreover, the measures have not undergone a rigorous review for how accurately the components, specifically the International Classification of Diseases, Ninth Revision (ICD-9) codes, represent the chronic conditions that comprise the measures. We performed a comprehensive, structured literature review of research studies on the accuracy of ICD-9 codes validated using external sources across an inventory of 81 chronic conditions. The conditions as a weighted measure set have previously been demonstrated to impact not only mortality but also physical and mental health-related quality of life.

Methods

For each of 81 conditions we performed a structured literature search with the goal to identify 1) studies that externally validate ICD-9 codes mapped to each chronic condition against an external source of data, and 2) the accuracy of ICD-9 codes reported in the identified validation studies. The primary measure of accuracy was the positive predictive value (PPV). We also reported negative predictive value (NPV), sensitivity, specificity, and kappa statistics when available. We searched PubMed and Google Scholar for studies published before June 2019.

Results

We identified studies with validation statistics of ICD-9 codes for 51 (64%) of 81 conditions. Most of the studies (47/51 or 92%) used medical chart review as the external reference standard. Of the validated using medical chart review, the median (range) of mean PPVs was 85% (39–100%) and NPVs was 91% (41–100%). Most conditions had at least one validation study reporting PPV ≥70%.

Conclusions

To help facilitate the use of patient-centered measures of multimorbidity in administrative data, this review provides the accuracy of ICD-9 codes for chronic conditions that impact a universally valued patient-centered outcome: health-related quality of life. These findings will assist health services studies that measure chronic disease burden and risk-adjust for comorbidity and multimorbidity using patient-centered outcomes in administrative data.

Multimorbidity and Cognitive Decline Over 14 Years in Older Americans

BACKGROUND

Multimorbidity is associated with greater disability and accelerated declines in physical functioning over time in older adults. However, less is known about its effect on cognitive decline.

METHODS

Participants without dementia from the Health and Retirement Study were interviewed about physician-diagnosed conditions, from which their multimorbidity-weighted index (MWI) that weights diseases to physical functioning was computed. We used linear mixed-effects models to examine the predictor MWI with the modified Telephone Interview for Cognitive Status (TICSm, global cognition), 10-word immediate recall and delayed recall, and serial 7s outcomes biennially after adjusting for baseline cognition and covariates.

RESULTS

Fourteen thousand two hundred sixty-five participants, 60% female, contributed 73,700 observations. Participants had a mean ± SD age 67 ± 9.3 years and MWI 4.4 ± 3.9 at baseline. Each point increase in MWI was associated with declines in global cognition (0.04, 95% CI: 0.03-0.04 TICSm), immediate recall (0.01, 95% CI: 0.01-0.02 words), delayed recall (0.01, 95% CI: 0.01-0.02 words), and working memory (0.01, 95% CI: 0.01-0.02 serial 7s; all p < .001). Multimorbidity was associated with faster declines in global cognition (0.003 points/year faster, 95% CI: 0.002-0.004), immediate recall (0.001 words/year faster, 95% CI: 0.001-0.002), and working memory (0.006 incorrect serial 7s/year faster, 95% CI: 0.004-0.009; all p < .001), but not delayed recall compared with premorbid slopes.

CONCLUSIONS

Multimorbidity using a validated index weighted to physical functioning was associated with acute decline in cognition and accelerated and persistent cognitive decline over 14 years. This study supports an ongoing geriatric syndrome of coexisting physical and cognitive impairment in adults with multimorbidity. Clinicians should monitor and address both domains in older multimorbid adults.

The Relationship of Loneliness to End-of-Life Experience in Older Americans: A Cohort Study

OBJECTIVES

Little is known about the relationship between loneliness and end-of-life (EOL) experience including symptom burden, intensity of care, and advance care planning among older adults.

DESIGN

Secondary analysis of the Health and Retirement Study (HRS).

SETTING

Population based.

PARTICIPANTS

Decedents older than 50 years who died between 2004 and 2014 (n = 8700). Exclusions included those who were ineligible for surveys assessing loneliness (n = 2932) or had missing or incomplete loneliness or symptom data (n = 2872).

MEASUREMENTS

Individuals were characterized as lonely based on responses to the three-item Revised University of California, Los Angeles Loneliness Scale in the most recent HRS survey before death. Outcomes were proxy reports of total EOL symptom burden, intensity of EOL care (eg, late hospice enrollment, place of death, hospitalizations, use of life support), and advance care planning. Results were expressed as adjusted odds ratios (aORs) with 95% confidence intervals (CIs).

RESULTS

One-third of 2896 decedents (n = 942) were lonely. After adjusting for demographics, socioeconomic status, multimorbidity, depressive symptoms, family and friends, and social support, loneliness was independently associated with increased total symptom burden at EOL (ß = .13; P = .004). Compared with nonlonely individuals, lonely decedents were more likely to use life support in the last 2 years of life (35.5% vs 29.4%; aOR = 1.36; 95% CI = 1.08-1.71) and more likely to die in a nursing home (18.4% vs 14.2%; aOR = 1.78; 95% CI = 1.30-2.42). No significant differences in other measures of intense care (late hospice enrollment, number of hospitalizations, or dialysis use) or likelihood of advance care planning were observed.

CONCLUSION

Lonely older people may be burdened by more symptoms and may be exposed to more intense EOL care compared with nonlonely people. Interventions aiming to screen for, prevent, and mitigate loneliness during the vulnerable EOL period are necessary. J Am Geriatr Soc 68:1064-1071, 2020.

Multimorbidity in Medicare Beneficiaries: Performance of an ICD-Coded Multimorbidity-Weighted Index

OBJECTIVES

Most older adults have multimorbidity that impairs physical functioning, but it is difficult to quantify using claims data. We previously developed and validated a multimorbidity-weighted index (MWI) that embeds physical functioning through disease weightings. We mapped these conditions to International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes and compared them with existing indices.

DESIGN

Population-based prospective cohort.

SETTING

Respondents to the 2006-2016 waves of the Health and Retirement Study (HRS) with linked Medicare claims data and continuous enrollment in 2006.

PARTICIPANTS

Community-dwelling Medicare-eligible HRS participants (N = 9923; mean age = 75.5 ± 8.5 y).

MEASUREMENTS

Individuals were followed for future physical functioning (2006-2014) and mortality (2007-2016). MWI conditions were mapped to ICD-9-CM codes to produce an ICD-coded MWI (MWI-ICD). We compared MWI-ICD, simple disease count, Charlson, Elixhauser, and the health-related quality of life comorbidity index (HRQOL-CI) through distributions, hazard ratios for mortality, and relationships with future physical functioning.

RESULTS

MWI-ICD exhibited the broadest distribution and most unique values (5891). Left censoring was most pronounced for Charlson (34.3% score = 0) and Elixhauser (13.1% score = 0) vs MWI (5.0% score = 0). Hazard ratios and concordance (C)-statistics for mortality across extreme quartiles were similar for MWI-ICD, Elixhauser, and Charlson but lower for disease count and the HRQOL-CI. For physical functioning, MWI-ICD yielded the greatest contrast across extreme quartiles and overall coefficient of determination (R² ).

CONCLUSION

MWI-ICD was significantly associated with mortality and future physical functioning and comparable with established metrics for mortality prediction although not weighted to mortality. MWI-ICD successfully captures diseases accumulation and functioning in claims data. J Am Geriatr Soc 68:999-1006, 2020.

QUANTIFYING THE BURDEN OF HOSPITALIZED DAYS IN MEDICARE BENEFICIARIES WITH MULTIMORBIDITY

Multimorbidity predicts several health outcomes including physical and cognitive functioning and mortality. Multimorbidity also predicts healthcare burden, but this has not been studied using a patient-centered measure that weights conditions by their impact on physical functioning. Health and Retirement Study participants were continuously enrolled in Medicare Parts A/B 1-year before and after the 2012-2013 HRS interview. Medicare claims were used to compute ICD-coded multimorbidity-weighted index (MWI-ICD) by summing physical functioning-weighted conditions. Given excess observations of zero hospital days (78.1%), we used zero-inflated Poisson regression to examine the association between multimorbidity and hospitalized days. First, logit models predicted membership into the zero-coded “no hospitalizations” group. Second, Poisson models predicted hospital days for participants not in the zero-coded group. We converted adjusted regression coefficients to odds ratios to report odds of zero hospitalized days. To compare model fit between MWI-ICD and simple disease count we used AICs. The final sample N=5201 participants had mean age 77.6+/-11.6 years, MWI-ICD 16.5+/-11.6, and 1.9+/-6.0 (range 0-90) hospitalized days. Each 1-point increase in MWI-ICD was associated with 4.3% decreased odds of zero hospitalized days (OR=0.96, 95%CI: 0.95-0.96) and 2% increased number of expected hospitalized days (IRR=1.02, 95%CI: 1.01-1.03) over one year in adjusted models. MWI-ICD had a lower AIC than simple disease count. Multimorbidity measured with MWI-ICD was associated with a decreased odds of zero hospitalized days and an increased number of expected hospitalized days. Multimorbidity contributes greatly to patient burden through increased hospitalization and is better captured through an index weighting conditions to physical functioning.

Physical Functioning Decline and Mortality in Older Adults With Multimorbidity: Joint Modeling of Longitudinal and Survival Data

Background

Multimorbidity is common among older adults and strongly associated with physical functioning decline and increased mortality. However, the full spectrum of direct and indirect effects of multimorbidity on physical functioning and survival has not been quantified. We aimed to determine the longitudinal relationship of multimorbidity on physical functioning and quantify the impact of multimorbidity and multimorbidity-attributed changes in physical functioning on mortality risk.

Methods

The Health and Retirement Study (HRS) is a nationally representative population-based prospective cohort of adults aged 51 or older. In 2000, participants were interviewed about physician-diagnosed chronic conditions, from which their multimorbidity-weighted index (MWI) was computed. Between 2000 and 2011, participants reported their current physical functioning using a modified Short Form-36. With MWI as a time-varying exposure, we jointly modeled its associations with physical functioning and survival.

Results

The final sample included 74,037 observations from 18,174 participants. At baseline, participants had a weighted mean MWI of 4.6 ± 4.2 (range 0-36.8). During follow-up, physical functioning declined: -1.72 (95% confidence interval [CI] -1.77, -1.67, p < .001) HRS physical functioning units per point MWI in adjusted models. Over follow-up, 6,362 (34%) participants died. Mortality risk increased 8% (hazard ratio 1.08, 95% CI 1.07-1.08, p < .001) per point MWI in adjusted models. Across all population subgroups, MWI was associated with greater physical functioning decline and mortality risk.

Conclusions

Multimorbidity and its associated decline in physical functioning were significantly associated with increased mortality. These associations can be predicted with an easily interpreted and applied multimorbidity index that can better identify and target adults at increased risk for disability and death.

Multimorbidity and Mental Health-Related Quality of Life and Risk of Completed Suicide

BACKGROUND

Physical functioning indexed multimorbidity is strongly associated with long-term mortality, but its role in poor mental health has not been quantified.

METHODS

A total of 252 002 community-dwelling adults in the Nurses' Health Study (NHS), NHS II, and Health Professionals Follow-up Study (HPFS) prospective cohorts reported physician-diagnosed diseases and the Short Form-36 over 8 years and had 24-year follow-up for suicide mortality. We quantified multimorbidity using a multimorbidity-weighted index (MWI). We used multivariable-adjusted proportional hazards models with competing risks for suicide mortality and mixed-effects models to estimate mental health-related quality of life (HRQOL).

RESULTS

Multimorbidity was associated with an increased risk of suicide mortality in an approximately linear manner, with roughly two- to threefold higher risk in adults with the highest vs lowest quartile MWI in adjusted models: NHS hazard ratio (HR) = 3.01 (95% confidence interval [CI] = 1.48-6.11); NHS II HR = 3.04 (95% CI = 1.82-5.09); HPFS HR = 1.74 (95% CI = 1.08-2.81). Greater MWI was associated with worse mental HRQOL 8 years later across all scales and the mental component summary (MCS) in a dose-response manner. This association was attenuated but persisted after adjustment for baseline mental HRQOL and other covariates. Adults with the highest quartile MWI had lower MCS in adjusted models compared with those with the lowest quartile MWI: NHS ß = -0.61 (95% CI = -0.78 to -0.44); NHS II ß = -1.25 (95% CI = -1.44 to -1.06).

CONCLUSION

Multimorbidity is associated with substantially higher suicide mortality risk and worse mental HRQOL across all available scales, even when indexed to physical functioning. These results highlight the substantial mental health burden imposed by multimorbidity at all ages and sexes. J Am Geriatr Soc 67:511-519, 2019.

Multimorbidity is associated with uptake of influenza vaccination

OBJECTIVE

Patients with chronic conditions have higher rates of severe influenza-related illness and mortality. However, influenza vaccination coverage in high-risk populations continues to be suboptimal. We describe the association between cumulative disease morbidity, measured by a previously validated multimorbidity index, and influenza vaccination among community-dwelling adults.

METHODS

We obtained interview and medical record data for participants  ≥18 years who sought outpatient care for influenza-like illness between 2011 and 2016 as part of an outpatient-based study of influenza vaccine effectiveness. We defined cumulative disease morbidity by using medical diagnosis codes to calculate a multimorbidity-weighted index (MWI) for each participant. MWI and influenza vaccination status was evaluated by logistic regression. Akaike information criterion was calculated for all models.

RESULTS

Overall, 1458 (48%) of participants out of a total of 3033 received influenza vaccination. The median MWI was 0.9 (IQR 0.00-3.5) and was higher among vaccinated participants (median 1.6 versus 0.0; p < 0.001). We found a positive linear association between MWI and vaccination, and vaccination percentages were compared between categories of MWI. Compared to patients with no multimorbidity (MWI = 0), odds of vaccination were 17% higher in the second category (MWI 0.01-1.50; [OR: 1.17, 95% CI: 0.92-1.50]), 58% higher in the third category (MWI 1.51-3.00; [OR: 1.58, 95% CI: 1.26-1.99]), 130% higher in the fourth category (MWI 3.01-6.00; [OR: 2.30, 95% CI: 1.78-2.98]) and 214% higher in the fifth category (MWI 6.01-45.00;[OR: 3.14, 95% CI: 2.41-4.10]). Participants defined as high-risk had 86% greater odds of being vaccinated than non-high-risk individuals (OR: 1.86, 95% CI: 1.56-2.21). The AIC was lowest for MWI compared with high-risk conditions.

CONCLUSIONS

Our results suggest a dose response relationship between level of multimorbidity and likelihood of influenza vaccination. Compared with high-risk condition designations, MWI provided improved precision and a better model fit for the measurement of chronic disease and influenza vaccination.

[The publication of the Medicine News and its influence on the spread of modern-western medicines in China and its role in western medicine communication]

Medicine News, first published in 1880, was the earliest western medicine journal founded in China, playing an important role in the history of Chinese modern journals and the history of western medicine communication. Today, no original copies of this journal survive in China. Quotations, citations and comments of some newspapers and periodicals on it at the time, reveal that the publication aim of this journal was to disseminate knowledge of western medicine to the Chinese people, that its editorial policy was "showing western medicine is superior to traditional Chinese medicine" , and that its communication of western medicine knowledge was also based on this policy. Medicine News reported on an international medical academic conference held in London for the first time, and it is worth mentioning that thousands of people attended the meeting. Medicine News is known to have promoted western medicine communication in China to an advanced and more up-to-date level. At the same time, its editorial policy and strategy had a great influence on the editing and publication of western medicine journals in the late Qing Dynasty and the Republic of China.

Multimorbidity and Physical and Cognitive Function: Performance of a New Multimorbidity-Weighted Index

Background

Multimorbidity is an important health outcome but is difficult to quantify. We recently developed a multimorbidity-weighted index (MWI) and herein assess its performance in an independent nationally-representative cohort.

Methods

Health and Retirement Study (HRS) participants completed an interview on physician-diagnosed chronic conditions and physical functioning. We determined the relationship of chronic conditions on physical functioning and validated these weights with the original, independently-derived MWI. We then determined the association between MWI with physical functioning, grip strength, gait speed, basic and instrumental activities of daily living (ADL/IADL) limitations, and the modified Telephone Interview for Cognitive Status (TICS-m) in adjusted models.

Results

Among 20,509 adults, associations between chronic conditions and physical functioning varied several-fold. MWI values based on weightings in the HRS and original cohorts correlated strongly (Pearson's r = .92) and had high classification agreement (κ statistic = .80, p < .0001). Participants in the highest versus lowest MWI quartiles had weaker grip strength (-2.91 kg, 95% confidence interval [CI]: -3.51, -2.30), slower gait speed (-0.29 m/s, 95% CI: -0.35, -0.23), more ADL (0.79, 95% CI: 0.71, 0.87) and IADL (0.49, 95% CI: 0.44, 0.55) limitations, and lower TICS-m (-0.59, 95% CI: -0.77, -0.41) (all p < .001). We observed monotonic graded relationships for all outcomes with increasing MWI quartiles.

Conclusion

A multimorbidity index weighted to physical functioning performed nearly identically in a nationally-representative cohort as it did in its development cohorts, confirming broad generalizability. MWI was strongly associated with subjective and objective physical and cognitive performance. Thus, MWI serves as a valid patient-centered measure of multimorbidity, an important construct in research and clinical practice.

Multimorbidity, Mortality, and Long-Term Physical Functioning in 3 Prospective Cohorts of Community-Dwelling Adults

Multimorbidity is prevalent, but its optimal quantification and associations with mortality rate and physical functioning in young through older adults are uncertain. We used data collected using the Short Form-36 in the Nurses' Health Study (enrollment started in 1976), Nurses' Health Study II (begun in 1989), and Health Professionals Follow-up Study (begun in 1986) to identify associations of a multimorbidity-weighted index (MWI) and common alternative indices with mortality and future physical functioning. We used Cox proportional hazard ratios to determine incident 10-year mortality and general linear models to obtain coefficients for the associations of MWI with 4- and 8-year physical functioning. At baseline, mean values for the 219,950 participants were 55.0 (standard deviation, 3.7) years for age; 3.8 (range, 0-51) for MWI; 2.7 (range, 0-23) for disease count, and 0.43 (range, 0-13) for Charlson Comorbidity Index (CCI). During follow-up, 23,709 deaths (10.8%) occurred. CCI, MWI, and disease count were 0 for 77%, 12%, and 19% of participants, respectively. When comparing persons in the highest quartiles with those in the lowest, the hazard ratios for mortality were 6.04 (95% confidence interval (CI): 6.00, 6.09; P for trend < 0.0001) for the MWI, 4.86 (95% CI: 4.81, 4.91; P for trend < 0.0001) for disease count, and 3.29 (95% CI: 3.26, 3.32; P for trend < 0.0001) for the CCI. For future physical functioning, MWI had the best model fit and explained the greatest variance. Multimorbidity has important associations with future physical functioning and mortality that are easily captured with a readily measured index.

Multimorbidity of four cardiometabolic and chronic pulmonary disease groups: prevalence and attributable fraction in US adults, 2007-2012

BACKGROUND

Cardiometabolic and chronic pulmonary diseases may be associated with modifiable risk factors that can be targeted to prevent multimorbidity.

OBJECTIVES

(i) Estimate the prevalence of multimorbidity across four cardiometabolic and chronic pulmonary disease groups; (ii) compare the prevalence of multimorbidity to that of one disease and no disease; and (iii) quantify population attributable fractions (PAFs) for modifiable risk factors of multimorbidity.

DESIGN

Data from adults aged 18-79 years who participated in the US National Health and Nutrition Examination Survey 2007-2012 were examined. Multimorbidity was defined as ≥2 co-occurring diseases across four common cardiometabolic and chronic pulmonary disease groups. Multivariate-adjusted PAFs for poverty, obesity, smoking, hypertension, and low high-density lipoprotein (HDL) cholesterol were estimated.

RESULTS

Among 16,676 adults, the age-standardized prevalence of multimorbidity was 9.3%. The occurrence of multimorbidity was greater with age, from 1.5% to 5.9%, 15.0% and 34.8% for adults aged 18-39, 40-54, 55-64 and 65-79 years, respectively. Multimorbidity was greatest among the poorest versus non-poorest adults and among blacks versus other races/ethnicities. Multimorbidity was also greater in adults with obesity, hypertension, and low HDL cholesterol. Risk factors with greatest PAFs were hypertension (38.8%; 95% confidence interval [CI] 29.4-47.4) and obesity (19.3%; 95% CI 10.2-28.2).

CONCLUSIONS

In the USA, 9.3% of adults have multimorbidity across four chronic disease groups, with a disproportionate burden among older, black, and poor adults. Our results suggest that targeting two intermediate modifiable risk factors, hypertension and obesity, might help to reduce the prevalence of multimorbidity in US adults.

Diverse Cumulative Impact of Chronic Diseases on Physical Health-Related Quality of Life: Implications for a Measure of Multimorbidity

Debate continues on how to measure and weight diseases in multimorbidity. We quantified the association of a broad range of chronic diseases with physical health-related qualify of life and used these weights to develop and validate a multimorbidity weighted index (MWI). Community-dwelling adults in 3 national, prospective studies-the Nurses' Health Study (n = 121,701), Nurses' Health Study II (n = 116,686), and Health Professionals Follow-up Study (n = 51,529)-reported physician-diagnosed diseases and completed the Short Form 36 physical functioning (PF) scale over multiple survey cycles between 1992 and 2008. Mixed models were used to obtain regression coefficients for the impact of 98 morbid conditions on PF. The MWI was formed by weighting conditions by these coefficients and was validated through bootstrapping. The final sample included 612,592 observations from 216,890 participants (PF mean score = 46.5 (standard deviation, 11)). The association between diseases and PF varied severalfold (median, -1.4; range, -10.6 to 0.8). End-stage organ diseases were associated with the greatest reduction in PF. The mean MWI score was 4.8 (median, 3.7; range, 0-53), and the mean number of comorbid conditions was 3.3 (median, 2.8; range, 0-34). This validated MWI weights diseases by severity using PF, a patient-centered outcome. These results suggest that simple disease count is unlikely to capture the full impact of multimorbidity on health-related quality of life, and that the MWI is feasible and readily implemented.

Bidirectional associations between alcohol consumption and health-related quality of life amongst young and middle-aged women

BACKGROUND

Evidence from cross-sectional studies has suggested a positive association between moderate alcohol consumption and health-related quality of life but prospective data remain scarce.

OBJECTIVES

To examine the bidirectional relationships between alcohol consumption and health-related quality of life using a longitudinal study design.

METHODS

A total of 92 448 participants of the Nurses' Health Study II reported their alcohol consumption (in 1991, 1995, 1999 and 2003) and health-related quality of life (in 1993, 1997 and 2001). Using generalized estimating equations, we modelled the physical and mental component summary (PCS and MCS) scores as a function of alcohol consumption 2 years earlier (n = 88 363) and vice versa (n = 84 621).

RESULTS

Greater alcohol consumption was associated with better PCS scores 2 years later in a dose-response manner up to ~1 serving daily [mean difference (β) = 0.67 ± 0.06 PCS units, for moderate versus infrequent drinkers]. After adjustment for previous PCS, a similar but attenuated pattern was observed (β = 0.33 ± 0.07). Moderate alcohol consumption was not related to MCS, whereas moderate-to-heavy alcohol consumption was associated with lower MCS scores (β = -0.34 ± 0.15). Higher PCS scores were associated with greater alcohol consumption 2 years later, also after adjustment for previous alcohol consumption (β = 0.53 ± 0.05 g day(-1) ). MCS was not associated with alcohol consumption 2 years later.

CONCLUSION

Amongst young and middle-aged women, moderate alcohol intake was associated with a small improvement in physical health-related quality of life 2 years later and vice versa. Moderate alcohol consumption was not associated with mental health-related quality of life in either direction.

Predictors of statin adherence, switching, and discontinuation in the USAGE survey: understanding the use of statins in America and gaps in patient education

BACKGROUND

Although statins have been shown to reduce cardiovascular disease mortality, less than half of U.S. adults achieve their low-density lipoprotein cholesterol goal. In many patients initiated on a statin, adherence rates decrease over time.

OBJECTIVE

To characterize current and former statin users, identify reasons for the discontinuation or switching of statins, and identify factors associated with adherence.

METHODS

The USAGE survey is a cross-sectional, self-administered Internet-based survey of 10,138 U.S. adults fielded September to October 2011. The following statin users were identified and compared: adherent nonswitchers, adherent switchers, non-adherent switchers, and discontinuers. Univariate and multivariate models using a priori covariates for adherence and discontinuation were examined.

RESULTS

Most participants were current statin users who adhered with their prescribed statin (82.5%, n = 8371). Former statin users or discontinuers (12%, n = 1220) cited muscle pain, a side effect, as the primary reason for discontinuation (60%), followed by cost (16%), and then perceived lack of efficacy (13%). Discontinuers were less satisfied with their physicians' explanation of cholesterol treatment, more likely to use the Internet to research statins, and less likely to undergo frequent cholesterol monitoring. Among adherent statin users, the primary reasons for switching were muscle side effects (33%) and cost (32%). Individuals at risk for non-adherence included those with low household income, those who experienced muscle pain as a side effect while on statin therapy, and those taking medication for cardiovascular disease.

CONCLUSION

Statin-related muscle side effects are common and contribute significantly to rates of discontinuation, switching, and non-adherence. Improved physician patient communication about side effects and benefits of statins are necessary to improve both adherence and outcomes.

Effects of eicosapentaenoic acid versus docosahexaenoic acid on serum lipids: a systematic review and meta-analysis

Omega-3 fatty acid supplements containing both eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) have been shown to reduce triglycerides but also increase low-density lipoprotein (LDL). Whether EPA or DHA given as monotherapy has differential effects on serum lipoproteins has not been systematically evaluated. We performed a meta-analysis of randomized placebo-controlled trials of monotherapy with EPA (n=10), DHA (n=17), or EPA versus DHA (n=6). Compared with placebo, DHA raised LDL 7.23 mg/dL (95% CI, 3.98–10.5) whereas EPA non-significantly reduced LDL. In direct comparison studies, DHA raised LDL 4.63 mg/dL (95% CI, 2.15–7.10) more than EPA. Both EPA and DHA reduced triglycerides, with a greater reduction by DHA in direct comparison studies. DHA also raised high-density lipoprotein (4.49 mg/dL; 95% CI, 3.50–5.48) compared with placebo, whereas EPA did not. Although EPA and DHA both reduce triglycerides, they have divergent effects on LDL and high-density lipoprotein. Further research is needed to elucidate the mechanisms and significance of these differences.

Vitamin D and multiple health outcomes in the Harvard cohorts

The hypothesis that vitamin D is inversely associated with multiple health outcomes has been studied in the Harvard cohorts, including the Nurses' Health Study I (n=121,700 female nurses aged 37-64 at baseline in 1984), Nurses' Health Study II (n=116,671 female nurses aged 27-44 years at baseline in 1991), Health Professionals Follow-up Study (n=51,529 male health professionals aged 40-75 years at baseline in 1986), and Physicians' Health Study (n=22 071 male physicians aged 40-84 years at baseline in 1982). These studies assessed vitamin D through circulating 25-hydroxyvitamin D, dietary and supplemental intake, predicted 25-hydroxyvitamin D, and vitamin D receptor polymorphisms. This review summarizes studies of vitamin D and various endpoints considered in these cohorts, including risk of cardiovascular disease, hypertension, elevated plasma C-peptide, various cancers, bone fractures, and multiple sclerosis. Based on the multiple observed benefits of vitamin D, this article postulates recommendations for vitamin D intake in the US population for reduced incidence of multiple health outcomes.

Vitamin D and prevention of colorectal adenoma: a meta-analysis

BACKGROUND

Vitamin D status is associated inversely with risk of colorectal cancer, but the association with adenoma risk is less clear. This meta-analysis examined the overall relationship between circulating (plasma or serum) 25-hydroxyvitamin D [25(OH)D], vitamin D intake (dietary, supplemental, or total), and colorectal adenoma incidence in published studies.

METHODS

A meta-analysis composed of 17 epidemiologic studies [1 cross-sectional, 9 case-control, and 7 cohort or nested case-control studies; 7 on 25(OH)D and 12 on vitamin D intake] published before December 2007 was done to examine the association between circulating 25(OH)D, vitamin D intake, and colorectal adenomas. Summary Peto odds ratios (OR) were computed for overall and stratified analyses.

RESULTS

Circulating 25(OH)D was inversely associated with risk of colorectal adenomas: the OR was 0.70 [95% confidence interval (95% CI), 0.56-0.87] for high versus low circulating 25(OH)D. The highest quintile of vitamin D intake was associated with an 11% marginally decreased risk of colorectal adenomas compared with low vitamin D intake (OR, 0.89; 95% CI, 0.78-1.02). For recurrent adenomas, there was a decreased risk of 12% (95% CI, 0.72-1.07) among individuals with high versus low vitamin D intake. The inverse associations appeared stronger for advanced adenoma [OR, 0.64; 95% CI, 0.45-0.90 for serum 25(OH)D and OR, 0.77; 95% CI, 0.63-0.95 for vitamin D intake], but the number of studies was small.

CONCLUSIONS

Both circulating 25(OH)D and vitamin D intake were inversely associated with colorectal adenoma incidence and recurrent adenomas. These results further support a role of vitamin D in prevention of colorectal adenoma incidence and recurrence.

Expression of p16, nm23-H1, E-cadherin, and CD44 gene products and their significance in nasopharyngeal carcinoma

OBJECTIVE

The present study was aimed to determine whether p16/MTS1, nm23-H1, E-cadherin, and CD44 proteins were expressed in nasopharyngeal carcinoma (NPC) and whether those expressions were pathologically significant in the progress of NPC.

METHOD

We examined non-cancerous nasopharyngeal mucosa (20 cases) and NPC (80 cases) using immunohistochemistry with six different types of monoclonal antibodies against p16, nm23-H1, E-cadherin, CD44H, CD44v3, and CD44v6 proteins.

RESULTS

The results showed that 1) the rates of positive p16 protein expression and of preserved E-cadherin protein expression in NPC were significantly lower than those in non-cancerous tissue (P <.01); 2) no significant difference in the rate of positive expression of nm23-H1, CD44H, CD44v3, and CD44v6 proteins were observed between non-cancerous nasopharyngeal mucosa and NPC; 3) no significant difference in the expression of those proteins were found by respective correlation analyses of sex, stage, and size of primary tumor in NPC; and 4) no significant difference in the rates of positive expression of CD44H, CD44v3, and CD44v6 proteins were observed in NPC between with and without lymph node metastasis, indicating that those gene products did not correlate with lymph node metastasis in NPC. However, there were inverse correlations between the expression of p16, nm23-H1, or E-cadherin protein and lymph node metastasis (P <.05), indicating that the expression of p16, nm23-H1, and E-cadherin gene were related to the carcinogenesis and tumor progression of NPC.

CONCLUSION

Detecting the expressions of those gene products may provide clinically valuable information for therapeutic strategy and for predicting the prognosis of patients with NPC.

Bilateral traumatic chylothorax: a complication of fracture-dislocation of the T-spine

Traumatic chylothorax is a rare complication of fracture-dislocation of the thoracic spine. Not treated adequately, it will be associated with high mortality and morbidity. A review of the English literature shows that bilateral traumatic chylothorax is rarely discussed. A case is presented of fracture-dislocation of the third thoracic vertebra combined with bilateral traumatic chylothorax following a motor vehicle accident. The mechanism of injury is described. The management strategies are, initially, conservative treatment including chest tube drainage, NPO with total parenteral nutrition (TPN), followed by medium-chain triglyceride diet. Without improvement, surgical measures such as mediastinal ligation of the thoracic duct should be considered.