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Category Archives: Epidemiology and outcomes research

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:
http://hqlo.biomedcentral.com/articles/10.1186/s12955-015-0355-9

References
[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.

Reference:
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.

Lifestyle factors and multimorbidity



By Martin Fortin

Many studies have unequivocally shown a close relationship between lifestyle factors and individual chronic diseases. More recently, the association of lifestyle risk factors with multimorbidity has been explored for physical activity, obesity, smoking, alcohol consumption, and nutrition. Some mixed results have been reported. However, the body mass index has been consistently found to be associated with multimorbidity.
In a recent study published in BMC Public Health [1], we analysed the association of accumulating risk factors in the same individual and multimorbidity. We found that accumulating unhealthy lifestyle factors progressively increased the likelihood of multimorbidity. The cross-sectional design of the study did not allow making a causal inference. However, the increase in the likelihood of multimorbidity with the combined effect of unhealthy lifestyle factors may be used to hypothesise that a person-centered approach promoting healthy lifestyles aiming to maximize the number of healthy lifestyles could be an intervention in the fight against multimorbidity.

1. Fortin M, Haggerty J, Almirall J, et al., Lifestyle factors and multimorbidity: a cross sectional study. BMC Public Health 2014;14:686.

Depression Screening and Multimorbidity

By Bhautesh Jani and Frances Mair

Our new paper published in Plos One examines the impact of routine depression screening, using the Hospital Anxiety and Depression Scale (HADS), and its relationship with multimorbidity and chronic disease management. In our study based on more than 125000 patients with chronic disease, the findings highlight the difficulties in implementing depression screening universally in primary care, despite incentivisation. Younger patients and those from deprived socio-economic background were more likely to have a positive result, when screened for depression symptoms. Importantly, depression screening did lead to an increase in the rate of anti-depressant prescribing in patients with chronic disease, which has significant resource implications.

In our study, depression screening was more often undertaken in patients with multimorbidity when compared to those with a single disease. Patients with multimorbidity had a greater chance of having a raised HADS score on depression screening, which resonates with the emerging evidence in this area. The crucial question will be to investigate the effect of depression screening in patients with chronic disease and multimorbidity on clinical outcomes, if any. The next phase of our project aims to address this question.

Comparisons of multi-morbidity in family practice – issues and biases

By Moira Stewart, Martin Fortin, Helena Britt, Christopher Harrison, and Heather Maddocks


A recent study published in Family Practice “Comparisons of multi-morbidity in family practice – issues and biases” [1] compared the methods and results of three separate prevalence studies of multi-morbidity from; i) the Saguenay region of Quebec [2]; ii) a sub-study of the Bettering Evaluation and Care of Health (BEACH) program in Australia [3,4]; and iii) the Deliver Primary Health Care Information (DELPHI) project in South-western Ontario [5,6].

A re-estimate of the prevalence rates using identical age-sex groups found multi-morbidity prevalence to vary by as much as 61%, where reported prevalence was 95% among females aged 45–64 in the Saguenay study, 46% in the BEACH sub-study and 34% in the DELPHI study.

Several aspects of the methods and study designs were identified as differing among the studies, including the sampling of frequent attenders, sampling period, source of data, and both the definition and count of chronic conditions.

The paper offers a guide for authors reporting the methods used in multi-morbidity prevalence research, recommending detailed descriptions of the type of sampling, completeness and accuracy of the source of data, and the definition of chronic conditions.

Further comparisons among multi-morbidity data using agreed upon standards for the definition of chronic conditions and the way to count multi-morbidity are recommended to assess the impact of these methodological variations.

References:

1 Stewart M, Fortin M, Britt H, Harrison C, Maddocks H.  Comparisons of multi-morbidity in family practice – issues and biases.  Family Practice. May 2013.  doi: 10.1093/fampra/cmt012.

2 Fortin M, Bravo G, Hudon C, Vanasse A, Lapointe L. Prevalence of multimorbidity among adults seen in family practice. Ann Fam Med 2005; 3: 223–8.

3 Britt HC, Harrison CM, Miller GC, Knox SA. Prevalence and patterns of multimorbidity in Australia. Med J Aust 2008; 189: 72–7.

4 Knox SA, Harrison CM, Britt HC, Henderson JV. Estimating prevalence of common chronic morbidities in Australia. Med J Aust 2008; 189: 66–70.

5 Stewart M, Thind A, Terry AL, et al. Multimorbidity in primary care: a study using electronic medical record (EMR) data. In: Thirty-Seventh Annual Meeting of North American Primary Care Research Group, Quebec, Canada, 14–18 November, 2009.

6 Stewart M, Thind A, Terry A, Chevendra V, Marshall JN. Implementing and maintaining a researchable database from electronic medical records—a perspective from an academic family medicine department. Healthc Policy 2009; 5: 26–39.

The impact of Multiple Chronic Diseases on ambulatory care use

By Elizabeth Muggah

Our paper, The impact of Multiple Chronic Diseases on ambulatory care use; a population based study in Ontario, Canada, was recently published in BMC Health Services Research. This study is an important addition to what we know about the burden of multimorbidity on the primary care system as we focused specifically on ambulatory health care use and looked at the burden of disease on both the patient and on the health system more broadly.

This research was completed using health administrative data housed at the Institute of Clinical Evaluative Sciences (ICES) in Toronto, Canada. We used well validated methods to search administrative data in one large province of Canada to identify persons who had at least one of nine common chronic diseases (diabetes, congestive heart failure, acute myocardial infarction, stroke, hypertension, asthma, chronic obstructive lung disease, peripheral vascular disease and end stage renal failure).  We then identified the number of outpatient primary care and specialist visits over a 2 year period.

We found that multiple chronic diseases were common among the Ontario population, (in 2009, 26.3% of Ontarians had one chronic disease, 10.3% had two diseases, and 5.6% had three or more diseases). The annual number of primary health care visits per patient increased significantly with each additional chronic disease and patients with two or more diseases made more than twice as many visits each year to primary health care providers compared to specialists. At the extremes of age we saw an increase in the number of primary care visits across all groups while specialist care dropped off. Looking from a health system perspective we found the largest total number of visits were made by those with no or one chronic disease compared to those with multiple diseases.

This study reinforces what we know about the considerable burden of illness felt by persons with multiple chronic diseases and confirms that these patients seek care disproportionately from their primary care providers.  However from a health system perspective those with no or one chronic disease are responsible for the largest number of ambulatory health care visits.  In our view continued investment in primary health care is needed both to care for those with multiple diseases as well as to maintain a focus on preventing the accumulation of chronic diseases with advancing age.  It would be important to explore these trends over time to see if the pattern of health care use we found is changing given the predicted rise in the prevalence of multiple chronic diseases with the aging of our population.

Multimorbidity, polypharmacy, referrals, and adverse drug events

By Amaia Calderón and Alexandra Prados-Torres

A paper entitled “Multimorbidity, polypharmacy, referrals, and adverse drug events: are we doing things well?” was recently published in the British Journal of General Practice. The work was carried out by members of the EpiChron Research Group on Chronic Diseases of the Aragon Health Sciences Institute in Spain, and its objective was to shed light on the interrelations between multimorbidity, polypharmacy, multiple referrals to specialised care, and the occurrence of adverse drug events (ADEs), in the context of a national healthcare system.

Results of this observational study demonstrate that multimorbidity, polypharmacy and multiple referrals are strongly and independently associated to occurrence of ADEs, even after adjusting for potential confounders. As the clinical situation of the patient becomes more complex and requires the intervention of different specialists, the likelihood of a lack of coordination among professionals and potential interactions among prescribed medications could favour the occurrence of undesirable effects, such as ADEs.

As indicated by Starfield et al[1] a decade ago, it is necessary, now more than ever, to design strategies that focus on individual’s health problems in their totality, rather than examining each of the patient’s illnesses individually. This approach is important given the high frequency of multimorbidity in all stages of life, the proved risk of interactions between illnesses and medications or among medications, and the acknowledged impact of not doing so both for the healthcare system and the health of the patient.

This research, financed by the Spanish Institute of Health Carlos III, is framed within a wider project focused on the epidemiology of multimorbidity, utilization patterns and the response of healthcare systems to populations suffering from it.


[1] Starfield B, Lemke KW, Bernhardt T, et al. Comorbidity: implications for the importance of primary care in ‘case’ management. Ann Fam Med 2003; 1(1): 8–14.