Journal of comorbidity最新文献

The International Multimorbidity Symposium was held in November 2019 at Western University to achieve three main objectives: to discuss progress and findings from various jurisdictions; to facilitate collaboration through group discussion to identify strategies to move multimorbidity research forward; and to create concrete plans to ensure advances in multimorbidity research and knowledge can be achieved through cross-national partnership. This event included keynote presentations, elevator pitch presentations and breakout sessions and there was a total of 35 attendees from eight countries, representing diverse disciplines and training levels. The overall themes arising from the event were: the importance of integrating the study and management of multimorbidity from both the primary care and public health perspectives; meaningful engagement and collaboration with patients and caregivers to understand key dimensions of multimorbidity; the considerable benefit of collaborative international partnerships; and the need to spread and scale innovations for health care systems that can better respond to the complex needs of patients and caregivers who are living with multimorbidity. Finally, it was well-acknowledged among the attendees that expanding the collaboration and discussion among international colleagues via in-person and virtual events will be important to move multimorbidity research forward.

Objective: To examine the relationship between multimorbidity and mortality, and whether relationship varied by material deprivation/rural location and by age.

Methods: Retrospective population-based cohort study conducted using 2013-14 data from previously created cohort of Ontario, Canada residents classified according to whether or not they had multimorbidity, defined as having 3+ of 17 chronic conditions. Adjusted rate ratios were calculated to compare mortality rates for those with and without multimorbidity, comparing rates by material deprivation/rural location, and by age group.

Results: There were 13,581,191 people in the cohort ages 0 to 105 years; 15.2% had multimorbidity. Median length of observation was 365 days. Adjusted mortality rate ratios did not vary by material deprivation/rural location; overall adjusted mortality rate ratio was 2.41 (95% CI 2.37-2.45). Adjusted mortality rate ratios varied by age with ratios decreasing as age increased. Overall rate ratio was 14.7 (95% CI 14.48-14.91). Children (0-17 years) had highest ratio, 40.06 (95% CI 26.21-61.22). Youngest adult age group (18-24 years) had rate ratio of 9.96 (95% CI 7.18-13.84); oldest age group (80+ years) had rate ratio of 1.97 (95% CI 1.94-2.04).

Conclusion: Compared to people without multimorbidity, multimorbidity conferred higher risk of death in this study at all age groups. Risk was greater in early and middle adulthood than in older ages. Results reinforce the fact multimorbidity is not just a problem of aging, and multimorbidity leads not only to poorer health and higher health care utilization, but also to a higher risk of death at a younger age.

Background: Child maltreatment is associated with long-term conditions (LTCs) in adulthood. Its relationship to multimorbidity (≥2 LTCs) is less clear. We explore the relationship between child maltreatment, multimorbidity and factors complicating management.

Methods: Cross-sectional analysis of 157,357 UK Biobank participants. Experience of four maltreatment types (physical/sexual/emotional/neglect) was identified. We explored the relationship between type, number and frequency of maltreatment and LTC count (0, 1, 2, 3, ≥4) using multinomial logistic regression. Binary logistic regression assessed the relationship between maltreatment and self-rated health, loneliness, social isolation, frailty and widespread pain in those with multimorbidity, adjusting for sociodemographics and lifestyle factors.

Results: 52,675 participants (33%) experienced ≥1 type of maltreatment; 983 (0.6%) experienced all four. Type, frequency and number of types of maltreatment were associated with higher LTC count. People experiencing four types of maltreatment were 5 times as likely to have a LTC count of ≥4 as those experiencing none (odds ratio (OR): 5.16; 99% confidence interval (CI): 3.77-7.07). Greater number of types of maltreatment was associated with higher prevalence of combined physical/mental health LTCs (OR: 2.99; 99% CI: 2.54-3.51 for four types of maltreatment). Compared to people who reported no maltreatment, people experiencing all four types of maltreatment were more likely to have poor self-rated health (OR: 3.56; 99% CI: 2.58-4.90), loneliness (OR: 3.16; 99% CI: 2.17-4.60), social isolation (OR: 1.45; 99% CI: 1.03-2.05), widespread pain (OR: 3.19; 99% CI: 1.87-5.44) and frailty (OR: 3.21; 99% CI: 2.04-5.05).

Conclusion: Peoplewith a history of maltreatment have higher LTC counts and potentially more complicated management needs reinforcing calls for early intervention.

Aim: To assess the feasibility of a patient-centered complex intervention for multimorbidity (CIM) based on general practice in collaboration with community health-care centers and outpatient clinics.

Methods: Inclusion criteria were age ≥18 years, diagnoses of two or more of three chronic conditions (diabetes, chronic obstructive pulmonary disease (COPD), and chronic heart conditions), and a hospital contact during the previous year. The CIM included extended consultations and nurse care manager support in general practice and intensified cross-sectorial collaboration. Elements included a structured care plan based on patients' care goals, coordination of services, and, if appropriate, shifting outpatient clinic visits to general practice, medication review, referral to rehabilitation, and home care. The acceptability dimension of feasibility was assessed with validated questionnaires, observations, and focus groups.

Results: Forty-eight patients were included (mean age 72.2 (standard deviation (SD) 9.5, range 52-89); 23 (48%) were men. Thirty-seven patients had two diseases; most commonly COPD and cardiovascular disease (46%), followed by diabetes and cardiovascular disease (23%), and COPD and diabetes (15%). Eleven (23%) patients had all three conditions. Focus group interviews with patients with multimorbidity identified three main themes: (1) lack of care coordination existed across health-care sectors before the CIM, (2) extended consultations provided better care coordination, and (3) patients want to be involved in planning their treatment and care. In focus groups, health-care professionals discussed two main themes: (1) patient-centered care and (2) culture and organizational change. Completion rates for questionnaires were 98% (47/48).

Conclusions: Patients and health-care professionals found the CIM acceptable.

Older patients presenting with acute myocardial infarction (AMI) often have comorbidities. Our objective was to examine how outcomes differ by cognitive and vision status in older AMI patients. We use data from a prospective cohort study conducted at 94 hospitals in the United States between January 2013 and October 2016 that enrolled men and women aged ≥75 years with AMI. Cognitive impairment (CI) was defined as telephone interview for cognitive status (TICS) score <27; vision impairment (VI) and activities of daily living (ADLs) were assessed by questionnaire. Of 2988 senior AMI patients, 260 (8.7%) had CI but no VI, 858 (28.7%) had VI but no CI, and 251 (8.4%) had both CI/VI. Patients in the VI/CI group were most likely to exhibit geriatric syndromes. More severe VI was associated with lower (worse) scores on the TICS (β -1.53, 95% confidence interval (CI) -1.87 to -1.18). In adjusted models, compared to participants with neither impairment, participants with VI/CI were more likely to die (hazard ratio 1.61, 95% CI 1.10-2.37) and experience ADL decline (odds ratio 2.11, 95% CI 1.39-3.21) at 180 days. Comorbid CIs and VIs were associated with high rates of death and worsening disability after discharge among seniors hospitalized for AMI. Future research should evaluate protocols to accommodate these impairments during AMI presentations and optimize decision-making and outcomes.

Objective: To examine agreement between administrative and self-reported data on the number of and constituent chronic conditions (CCs) used to measure multimorbidity.

Study design and setting: Cross-sectional self-reported survey data from four Canadian Community Health Survey waves were linked to administrative data for residents of Ontario, Canada. Agreement for each of 12 CCs was assessed using kappa (κ) statistics. For the overall number of CCs, perfect agreement was defined as agreement on both the number and constituent CCs. Jackknife methods were used to assess the impact of individual CCs on perfect agreement.

Results: The level of chance-adjusted agreement between self-report and administrative data for individual CCs varied widely, from κ = 5.5% (inflammatory bowel disease) to κ = 77.5% (diabetes), and there was no clear pattern on whether using administrative data or self-reported data led to higher prevalence estimates. Only 26.9% of participants had perfect agreement on the number and constituent CCs; 10.6% agreed on the number but not constituent CCs. The impact of each CC on perfect agreement depended on both the level of agreement and the prevalence of the individual CC.

Conclusion: Our results show that measuring agreement on multimorbidity is more complex than for individual CCs and that even small levels of individual condition disagreement can have a large impact on the agreement on the number of CCs.

Background: Heart failure patients often present with frailty and/or multi-morbidity, complicating care and service delivery. The Chronic Care Model (CCM) is a useful framework for designing care for complex patients. It assumes responsibility of several actors, including frontline providers and health-care administrators, in creating conditions for optimal chronic care management. This qualitative case study examines perceptions of care among providers and administrators in a large, urban health system in Canada, and how the CCM might inform redesign of care to improve health system functioning.

Methods: Sixteen semi-structured interviews were conducted between August 2014 and January 2016. Interpretive analysis was conducted to identify how informants perceive care among this population and the extent to which the design of heart failure care aligns with elements of the CCM.

Results: Current care approaches could better align with CCM elements. Key changes to improve health system functioning for complex heart failure patients that align with the CCM include closing knowledge gaps, standardizing treatment, improving interdisciplinary communication and improving patient care pathways following hospital discharge.

Conclusions: The CCM can be used to guide health system design and interventions for frail and multi-morbid heart failure patients. Addressing care- and service-delivery barriers has important clinical, administrative and economic implications.