Entete 3

Category Archives: Epidemiology and outcomes research

Perceived stress and multimorbidity

By Anders Prior
Multimorbidity and especially mental-physical multimorbidity is an increasing concern worldwide. It is well-known that psychiatric illness impairs the prognosis in persons with chronic physical disease. However, little is known on the impact of non-syndromic mental stress; mental stress is common in the general population, and psychological problems are an increasingly frequent reason for primary care contacts. In two studies, we aimed to determine whether perceived mental stress is associated with potentially preventable hospitalizations and all-cause mortality in persons with various degrees of multimorbidity.
The Danish Civil Registration System allowed us to individually link health survey data with prospectively collected data from Danish health registers creating a unique population-based cohort.  The Danish National Health Survey 2010 provided data on e.g. perceived stress and lifestyle factors on a representative sample of 118,000 Danish citizens aged 25 or older. Danish health registers provided data on hospitalizations, demographic and socioeconomic factors. We developed a new Danish multimorbidity index based on recorded diagnoses and redeemed medicine prescriptions on all Danish citizens identifying 39 mental and physical long-term conditions. We adjusted for and analyzed the modifying effect of multimorbidity on the study outcomes.
In general, we found that high stress perception was associated with multimorbidity, an increased number of potentially preventable hospitalizations and increased all-cause mortality after adjusting for mental-physical multimorbidity, socioeconomic factors and lifestyle where appropriate, and there often seemed to be dose-response relations. In absolute numbers, persons with multimorbidity had a poorer prognosis and psychiatric conditions aggravated this.
This may be the first step to understand the impact of mental stress on physical health, to discuss mental stress in a general practice setting, and to create the foundation for developing potential interventions and practice guidelines for patients with stress in general practice. Hopefully, this may lead to better care and improved life expectancy of people with stress and chronic disease.
Prior A, Fenger-Grøn M, Larsen KK, et al. The association between perceived stress and mortality among people with multimorbidity: A prospective population-based cohort study. Am J Epidemiol. 2016;184(3):199-210.
Prior A, Vestergaard M, Davydow DS, et al. Perceived stress, multimorbidity, and risk for hospitalizations for ambulatory care-sensitive conditions: A population-based cohort study. Med Care. 2017;55(2):131-139.

Different multimorbidity measures affect estimated levels of physical quality of life

By Aline Ramond-Roquin
Health-related quality of life is adversely affected by the presence of multimorbidity in a way that an increasing number of concurrent chronic conditions is associated with lower scores of health-related quality of life. Studies aiming to quantify the impact of multimorbidity on the quality of life show wide heterogeneity in terms of the intensity of this association but these studies also present other important methodological differences such as population studied, measure of quality of life, measure of multimorbidity, etc.
Most operational definitions of multimorbidity have been based on a simple count of conditions which are screened as present or not in a given individual from a predetermined list of conditions. Many different lists of potential conditions have been proposed, with some being as short as six conditions and others as long as 40.
We investigated the influence of the list of conditions on the estimated level of the physical component of health-related quality of life in individuals with multimorbidity and found that the length of the list of candidate conditions considered has a great impact on the estimations of physical health-related quality of life.
This argues for careful methodological consideration when measuring multimorbidity and its association with different outcomes. We conclude that standardization of the measure of multimorbidity is needed to allow the comparison of the results across different studies on multimorbidity.
The article describing this study was published on line (1) and is freely accessible to those interested in this subject.
1) Ramond-Roquin A, Haggerty J, Lambert M, Almirall J, Fortin M: Different Multimorbidity Measures Result in Varying Estimated Levels of Physical Quality of Life in Individuals with Multimorbidity: A Cross-Sectional Study in the General Population. Biomed Res Int. 2016;2016:7845438.

Prevalence of multimorbidity in the general population and in primary care practices

By Martin Fortin
It is known that settings affect estimation of the prevalence of multimorbidity. In a recently published paper  [1], we have compared estimates of the prevalence of multimorbidity in the general population and in primary care clinical practices.
The new aspect of this recent study was that prevalence in both settings was measured simultaneously, in the same region, and with the same methods. This way, we eliminated methodological limitations found in previous studies that prevented to conclude definitively the extent to which prevalence estimates differ in these two study populations [2].
Also, we explored the effect of using different operational definitions of multimorbidity on the differences of prevalence observed between the two sampled populations.
We concluded that there is a difference of about 10% in prevalence estimates of multimorbidity between samples from the general population and primary care clinical practices, with a higher prevalence in the latter setting. The difference of the prevalence between the two settings was not affected by the use of different operational definitions of multimorbidity.
1.- Mokraoui NM, Haggerty J, Almirall J, Fortin M. Prevalence of self-reported multimorbidity in the general population and in primary care practices: a cross-sectional study. BMC Res Notes. 2016;9:314.
2.- Fortin M, Hudon C, Haggerty J, van den Akker M, Almirall J. Prevalence estimates of multimorbidity: a comparative study of two sources. BMC Health Services Research. 2010;10:111.

Multimorbidity in adults from a southern Brazilian city

By Bruno P. Nunes
We are very satisfied to disseminate another recent paper about multimorbidity from Brazil in International Research Community on Multimorbidity (IRCMo) site. In this paper, we explore the occurrence and patterns (through Factorial Analysis) in Brazilian adults [1]. The manuscript used data from a population-based study carried out in 2012 in the individuals (20 or more years) households living in Pelotas, southern Brazil. Multimorbidity was evaluated by a list of 11 morbidities (based on medical diagnosis; Patient Health Questionnaire 9 for depression; and Anatomical Therapeutic Chemical index). The sample was made up of 2927 adults. Multimorbidity reached 29.1 % (95 % CI: 27.1; 31.1) for ≥2, and 14.3 % (95 % CI: 12.8; 15.8) for ≥3 morbidities. Two patterns of morbidities (cardio-metabolic and joint problems; and respiratory diseases) were observed. The high frequency and the observed patterns increase the need to address multimorbidity in Brazilian health policies and diseases guidelines.
To access the manuscript, please click in the following link:
Furthermore, we reinforce our invite to researchers interested in cross-country comparisons about a wide range of issues related to multimorbidity (prevalence, patterns, inequalities, use of health services and others). Contact e-mail for further information: nunesbp@gmail.com.
1) Nunes BP, Camargo-Figuera FA, Guttier M, de Oliveira PD, Munhoz TN, Matijasevich A, Bertoldi AD, Wehrmeister FC, Silveira MP, Thumé E, Facchini LA. Multimorbidity in adults from a southern Brazilian city: occurrence and patterns. Int J Public Health. 2016 Apr 22. [Epub ahead of print]

Multimorbidity in Brazil

By Bruno P. Nunes, Elaine Thumé, and Luiz A. Facchini
We are very satisfied to disseminate our recent paper in International Research Community on Multimorbidity (IRCMo) site. This community was and continues to be very important for our studies related to this topic in Brazil.
Despite worldwide importance of multimorbidity and the specific Brazilian context (more than 200 million inhabitants, rapid epidemiologic and demographic transitions, and relatively new universal health system), populational information about occurrence of multiple health problems is scarce in the country. Thus, data from a population-based survey that we conducted in 2008 were used to provide information and start works about multimorbidity in Brazilian context. The sample was comprised by 1593 elderly (≥60 years old) who lived in Bagé, a medium-sized city in Southern Brazil. The individuals were interviewed in their households through face-to-face interviews. In total, 17 morbidities were used and we measured multimorbidity according to two cutoff points: ≥2 and ≥3 morbidities. Descriptive analysis, and dyads and triads of diseases were calculated. We found that 94% of the sample presented, at least, one morbidity. High blood pressure – HBP – (55.3%) and spinal column disease (37.4%) were the diseases most frequent. Multimorbidity reached 81.3% (95 % CI: 79.3; 83.3) and 64.0 % (95% CI: 61.5; 66.4) of the individuals for ≥2 and ≥3 morbidities, respectively. As found in others studies, most vulnerable elderly presented higher occurrence of multiple diseases. For example, 87.1% of the elderly without schooling presented 2 or more diseases (22.3 percentage points higher than elderly which studied 8 years or more).  Another challenge to public health system was demonstrated by higher frequency of multimorbidity between individuals without health private plan and those who are living in Family Health Strategy (organizational axis of primary health care) catchment areas.
These results about multimorbidity in older adults from Brazil may provide initial information to address multiple diseases in clinical protocols and contribute to subsidize actions in health services to management of multimorbidity.
To access the full manuscript, please click in the following link: http://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-015-2505-8
Furthermore, we are drafting others papers about multimorbidity in Brazil, including evaluation of national-based studies. Therefore, we would like to invite researchers interested in cross-country comparisons about a wide range of issues related to multimorbidity (prevalence, patterns, inequalities, use of health services and others) to contact us. Contact e-mail for further information: nunesbp@gmail.com.
  • Reference: Nunes BP, Thumé E, Facchini LA: Multimorbidity in older adults: magnitude and challenges for the Brazilian health system. BMC Public Health 2015, 15(1):1172

Multimorbidity and functional decline: a systematic review

By Áine Ryan, Emma Wallace, Paul O’Hara, Susan M. Smith

Multimorbidity is recognised internationally as having a negative impact on patient outcomes. Functional decline is defined as developing difficulties with activities of daily living and is also independently associated with poorer health outcomes. We recently published a systematic review examining the association between multimorbidity and functional decline. We also examined the extent to which multimorbidity predicts future functional decline [1].
The review retrieved 37 relevant studies (nine cohort and 28 cross-sectional).The majority of studies (n= 31) demonstrated a consistent association between multimorbidity and poorer functional status. Future functional decline was more likely with increasing numbers of conditions and was also linked to condition severity.
We can be reasonably confident of the findings of this systematic review; as overall, there was minimal risk of bias in the included studies. However, variation in study participants, multimorbidity definitions, follow-up duration and outcome measures resulted in meta-analysis not being possible.
The findings of this systematic review are consistent with existing evidence linking multimorbidity and poorer health related quality of life. It also highlights a potential cumulative effect, in that both multimorbidity and functional decline independently predict poorer patient outcomes. This review examines one direction of effect, i.e. that baseline multimorbidity predicts future functional decline. Conversely, it is also possible that poor physical functioning will lead to worsening of multimorbidity, a relationship that our study group plans to examine in an ongoing prospective cohort study in Ireland [2].
This review suggests that functional decline needs to be carefully considered in patients with multimorbidity. Future research should focus on the development and testing of interventions which prioritise physical function in this patient group, particularly for patients with higher numbers of conditions and greater disease severity.

The complete article can be accessed at:

[1] Ryan A, Wallace E, O’Hara P, Smith SM. Multimorbidity and functional decline in community-dwelling adults: a systematic review. Health and Quality of Life Outcomes. DOI: 10.1186/s12955-015-0355-9.
[2] The Irish Longitudinal Study on Ageing (TILDA), Trinity College Dublin, Ireland. www.tilda.ie

Multimorbidity and the inequalities of global ageing: a cross-sectional study of 28 countries using the World Health Surveys

By Sara Afshar

Multimorbidity defined as the “the coexistence of two or more chronic diseases” in one individual, is
increasing in prevalence globally. Despite the growing recognition of the prevalence of multimorbidity amongst older adults, global prevalence have largely remained single-disease focused. Internationally, there is still limited evidence on the prevalence and social determinants of multimorbidity, particularly in low and middle income countries (LMICs).

In collaboration with the University of Southampton and the World Health Organisation, we examined the global patterns of multimorbidity and compared prevalence across different countries including LMICs. We extracted chronic disease data from 28 countries of the World Health Survey (2003) and examined the inter-country socio-economic differences by gross domestic product (GDP). Regression analyses were applied to examine associations of education with multimorbidity by region adjusted for age and sex distributions.

We found that the mean world standardized multimorbidity prevalence for LMICs was 7.8 % (95 % CI, 7.79 % – 7.83 %). In all countries, multimorbidity increased significantly with age. A positive but non–linear relationship was found between country GDP and multimorbidity prevalence. Trend analyses of multimorbidity by education suggested that there are intergenerational differences, with a more inverse education gradient for younger adults compared to older adults. Furthermore, higher education was significantly associated with a decreased risk of multimorbidity in the all-region analyses.

We concluded that multimorbidity is a global phenomenon, not just affecting older adults in high income countries. Policy makers worldwide therefore need to address these health inequalities, and support the complex service needs of a growing multimorbid population.

Afshar S, Roderick PJ, Kowal P, Dimitrov B and Hill AG. Multimorbidity and the inequalities of global ageing: a cross-sectional study of 28 countries using the World Health Surveys. BMC Public Health. 2015. 15:776

To access the full article: http://www.biomedcentral.com/1471-2458/15/776

Stroke, multimorbidity and polypharmacy in a nationally representative sample of patients in Scotland

By Dr Katie Gallacher, Prof Stewart Mercer and Prof Frances Mair

Our paper in BMC Medicine http://www.biomedcentral.com/1741-7015/12/151 examines the prevalence of multimorbidity and polypharmacy in a large, nationally representative sample of primary care patients, comparing those with and without stroke, adjusting for age, gender and deprivation. In this cross-sectional study of 1,424,378 adult participants from 314 primary care practices in Scotland, we analysed data on the presence of stroke and 39 other long-term conditions, as well as prescriptions for regular medications.
We found that both multimorbidity and polypharmacy were markedly more common in those with stroke compared to those without. Additionally, number of morbidities were very high in the stroke group (45% had 4 or more) as were numbers of prescriptions (13% had 11 or more). Both multimorbidity and polypharmacy put patients at risk of treatment burden, defined as the workload of healthcare for patients, and the impact of this on wellbeing. The findings from our study therefore have important implications for the redesign of stroke health services and clinical guidelines.

Multimorbidity in patients enrolled in a community-based methadone maintenance programme

By Tom Brett

The General Practice and Primary Health Care Research Unit at The University of Notre Dame Australia, Fremantle has published a new paper: ‘Multimorbidity in patients enrolled in a community-based methadone maintenance programme delivered through primary care’ (1). The study is a retrospective cohort study using electronic medical record review of patients attending a primary care-based methadone maintenance clinic in Western Australia. The clinic itself is part of a much larger medical centre that offers comprehensive primary health care. Multimorbidity in the methadone cohort was consistently higher across all age groups and contrasted with the comparator group where multimorbidity was positively correlated with age. We found the traditional S-shaped distribution curve of multimorbidity from mainstream practice was replaced by a consistently elevated plateau distribution among the methadone cohort. Our findings suggest challenging implications for the design and delivery of health care services to this population. Diane Arnold-Reed is lead author.

1-Multimorbidity in patients enrolled in a community-based methadone maintenance programme delivered through primary care. Journal of Comorbidity 2014; 4: 46-54.  Doi: 10.15256/joc.2014.4.42

Multimorbidity in a marginalised, street-health Australian population

By Tom Brett

A recent publication from The University of Notre Dame Australia, Fremantle in BMJ Open (1) deals with patterns, prevalence and disease severity of multimorbid chronic conditions among a street-based vulnerable and marginalized population.
Our research brings new information on a disadvantaged cohort of patients who access an innovative, accredited, mobile outreach primary care medical service.
We have again used the Cumulative Illness Rating Scale among the 2587 patients seen over a six year period in the Fremantle area of Western Australia.
Disease patterns and severity were compared with 4583 mainstream patients from a similar geographical area.
A key finding from our research is that this population develops chronic conditions at a much earlier age especially when compared with earlier research worldwide from mainstream practices.
A positive outcome from our research was the willingness of Aboriginal patients to engage with the mobile, outreach primary care medical service. This compares very favourably with the traditional low attendance patterns of Aboriginal patients with mainstream practices.

(1) Brett T, Arnold-Reed DE, Troeung L, Bulsara MK, Williams A, Moorhead RG. Multimorbidity in a marginalised, street-health Australian population: a retrospective cohort study. BMJ Open. 2014 Aug 19;4(8):e005461. doi: 10.1136/bmjopen-2014-005461.