A method of decision analysis quantifying the effects of age and comorbidities on the probability of deriving significant benefit from medical treatments

Background: The external validity, or generalizability, of trials and guidelines has been considered poor in the context of multiple morbidity. How multiple morbidity might affect the magnitude of benefit of a given treatment, and thereby external validity, has had little study. Objective: To provide a method of decision analysis to quantify the effects of age and comorbidity on the probability of deriving a given magnitude of treatment benefit. Design: We developed a method to calculate probabilistically the effect of all of a patient’s comorbidities on their underlying utility, or well-being, at a future time point. From this, we derived a distribution of possible magnitudes of treatment benefit at that future time point. We then expressed this distribution as the probability of deriving at least a given magnitude of treatment benefit. To demonstrate the applicability of this method of decision analysis, we applied it to the treatment of hypercholesterolaemia in a geriatric population of 50 individuals. We highlighted the results of four of these individuals. Results: This method of analysis provided individualized quantifications of the effect of age and comorbidity on the probability of treatment benefit. The average probability of deriving a benefit, of at least 50% of the magnitude of benefit available to an individual without comorbidity, was only 0.77%. Conclusion: The effects of age and comorbidity on the probability of deriving significant treatment benefits can be quantified for any individual. Even without consideration of other factors affecting external validity, these effects may be sufficient to guide decision-making.Journal of Comorbidity 2017;7(1):50–6

Chronic migraine, comorbidity and socioeconomic deprivation: cross-sectional analysis of a large nationally representative primary care database

Objectives: To examine mental and physical comorbidities in chronic migraine and the influence of socioeconomic status in a large, nationally representative dataset. Methods: Analysis of cross-sectional primary healthcare data on 1,468,404 adults in Scotland. Data on chronic migraine derived from prescription data, 31 physical, and seven mental health conditions were extracted. Prevalence rates were standardised by age-groups, gender, and neighbourhood deprivation, and odds ratio (OR) and 95% confidence intervals (CI) calculated for those with migraine compared to those without. Results: Those with chronic migraine were significantly more likely to have more conditions, with the biggest difference found for five or more conditions (migraine 11.7% vs. controls 4.9; OR 3.00 95% CI 2.78-3.22). In total, 25 of the 31 physical conditions were significantly more prevalent in the migraine group. The biggest differences after standardisation for age, sex and deprivation was for chronic pain (OR 4.33, 95% CI 4.12-4.55) followed by constipation and dyspepsia. For mental health conditions, the biggest differences after standardisation for age, sex and deprivation was for anxiety (OR 2.95, 95% CI 2.76-31.5) and depression (OR 2.94, 95% CI 2.81-3.08). Increasing deprivation was associated with more severe and complex comorbidity (five or more conditions), and with more combined mental and physical comorbidity in the migraine group compared with the controls group. Conclusions: In a large nationally representative sample in primary care, severe and complex comorbidity was commoner in people with chronic migraine compared with standardised controls, and this was exacerbated by living in areas of higher deprivation. The implications of this for patients and practitioners are discussed.Journal of Comorbidity 2017;7(1):89–9

Patients with multimorbidity and their experiences with the healthcare process: a scoping review

Background: The number of patients with multimorbidity (two or more conditions) is increasing. Observational research has shown that having multiple health problems is associated with poorer outcomes in terms of health, quality of care, and costs. Thus, it is imperative to understand how patients with multimorbidity experience their healthcare process. Insight into patient experiences can be used to tailor healthcare provision specifically to the needs of patients with multimorbidity. Objective: To synthesize self-reported experiences with the healthcare process of patients with multimorbidity, and identify overarching themes. Design: A scoping literature review that evaluates both qualitative and quantitative studies published in PubMed, Embase, MEDLINE, and PsycINFO. No restrictions were applied to healthcare setting or year of publication. Studies were included if they reported experiences with the healthcare process of patients with multimorbidity. Patient experiences were extracted and subjected to thematic analysis (interpretative), which revealed overarching themes by mapping their interrelatedness. Results: Overall, 22 empirical studies reported experiences of patients with multimorbidity. Thematic analysis identified 12 themes within these studies. The key overarching theme was the experience of a lack of holistic care. Patients also experienced insufficient guidance from healthcare providers. Patients also perceived system-related issues such as problems stemming from poor professional-to-professional communication. Conclusions: Patients with multimorbidity experience a range of system- and professional-related issues with healthcare delivery. This overview illustrates the diversity of aspects that should be considered in designing healthcare services for patients with multimorbidity.Journal of Comorbidity 2017;7(1):11–2

The Glasgow ‘Deep End’ Links Worker Study Protocol: a quasi-experimental evaluation of a social prescribing intervention for patients with complex needs in areas of high socioeconomic deprivation

Background: ‘Social prescribing’ can be used to link patients with complex needs to local (non-medical) community resources. The ‘Deep End’ Links Worker Programme is being tested in general practices serving deprived populations in Glasgow, Scotland. Objectives: To assess the implementation and impact of the intervention at patient and practice levels. Methods: Study design: Quasi-experimental outcome evaluation with embedded theory-driven process evaluation in 15 practices randomized to receive the intervention or not. Complex intervention: Comprising a practice development fund, a practice-based community links practitioner (CLP), and management support. It aims to link patients to local community organizations and enhance practices’ social prescribing capacity. Study population: For intervention practices, staff and adult patients involved in referral to a CLP, and a sample of community organization staff. For comparison practices, all staff and a random sample of adult patients. Sample size: 286 intervention and 484 comparator patients. Outcomes: Primary patient outcome is health-related quality of life (EQ-5D-5L). Secondary patient outcomes include capacity, depression/anxiety, self-esteem, and healthcare utilization. Practice outcome measures include team climate, job satisfaction, morale, and burnout. Outcomes measured at baseline and 9 months. Processes: Barriers and facilitators to implementation of the programme and possible mechanisms through which outcomes are achieved. Analysis plan: For outcome, intention-to-treat analysis with differences between groups tested using mixed-effects regression models. For process, case-study approach with thematic analysis. Discussion: This evaluation will provide new evidence about the implementation and impact of social prescribing by general practices serving patients with complex needs living in areas of high deprivation.Journal of Comorbidity 2017;7(1):1–1

Coronary heart disease risk in patients with schizophrenia: a Lebanese cross-sectional study

Background: Coronary heart disease (CHD) is a leading cause of premature death in patients with schizophrenia. CHD risk in Lebanese patients with schizophrenia remains unknown. Objectives: To (i) evaluate CHD risk of patients with schizophrenia in Lebanon; and (ii) detect the modifiable and non-modifiable factors affecting this risk. Methods: Cross-sectional study of 329 patients with schizophrenia aged 18–75 years. Ten-year hard CHD risk was calculated using the Framingham Risk Score. A logistic regression was conducted taking the dichotomous hard CHD (<10% and ≥10%) as the dependent variable. Results: Ten-year hard CHD risk was low (<10%) in 60.8% of patients, intermediate (10–20%) in 31.6%, and high (>20%) in 7.6%. Multivariate analysis showed that the mean 10-year hard CHD risk was 8.76±6.92 (10.82±6.83 in men and 3.18±2.90 in women). Ten-year hard CHD risk was higher in patients with the metabolic syndrome (odds ratio [OR] 2.67, confidence interval [CI] 1.54–4.64), a longer duration of schizophrenia (OR 1.03, CI 1.01–1.05), history of other medical illnesses (OR 2.02, CI 1.18–3.47), or participating in art therapy (OR 2.13, CI 1.25–3.64) or therapeutic education (OR 1.93, CI 0.93–4.01). Ten-year hard CHD risk was lower in patients receiving risperidone (OR 0.23, CI 0.08–0.68) or any anti-epileptic (OR 0.41, CI 0.24–0.73), or benzodiazepine (OR 0.33, CI 0.17–0.66) medication. Conclusion: CHD is prevalent in patients with schizophrenia in Lebanon. Physicians are recommended to monitor the components of the metabolic syndrome to identify patients with increased risk of cardiovascular diseases. *Equal contributionJournal of Comorbidity 2017;7(1):79–8

Heart failure and multimorbidity in Australian general practice

Background: Heart failure (HF) is a serious condition that mostly affects older people. Despite the ageing population experiencing an increased prevalence of many chronic conditions, current guidelines focus on isolated management of HF. Objective: To describe the burden of multimorbidity in patients with HF being managed in general practice in Australia. Design: Data from the Bettering the Evaluation And Care of Health (BEACH) programme were used to determine (i) the prevalence of HF, (ii) the number of co-existing long-term conditions, and (iii) the most common disease combinations in patients with HF. The study was undertaken over fifteen, 5-week recording periods between November 2012 and March 2016. Results: The dataset included a total of 25,790 general practitioner (GP) encounters with patients aged ≥45 years, collected by 1,445 GPs. HF had been diagnosed in 1,119 of these patients, a prevalence of 4.34% (95% confidence interval [CI] 3.99–4.68) among patients at GP encounters, and 2.08% (95% CI 1.87–2.29) when applied to the general Australian population overall. HF rarely occurred in isolation, with 99.1% of patients having at least one and 53.4% having six or more other chronic illnesses. The most common pair of comorbidities among active patients with HF was hypertension and osteoarthritis (43.4%). Conclusion: Overall, one in every 20−25 GP encounters with patients aged ≥45 years in Australia is with a patient with HF. Multimorbidity is a typical presentation among this patient group and guidelines for general practice must take this into account.Journal of Comorbidity 2017;7(1):44–4

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 monomorbidity 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% (95% confidence interval [CI] 8.8–9.9). Multimorbidity occurred in 34.8% (95% CI 32.4–37.2) of adults aged 65–79 years and in 1.5% (95% CI 1.2–1.9) of adults aged 18–40 years. 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 10.2–28.1). 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 reducing hypertension and obesity might yield over 50% reduction in the prevalence of multimorbidity of these diseases.*Equal contributionJournal of Comorbidity 2017;7(1):22–3

Multimorbidity: constellations of conditions across subgroups of midlife and older individuals, and related Medicare expenditures

Introduction: The Department of Health and Human Services’ 2010 Strategic Framework on Multiple Chronic Conditions called for the identification of common constellations of conditions in older adults. Objectives: To analyze patterns of conditions constituting multimorbidity (CCMM) and expenditures in a US representative sample of midlife and older adults (50–64 and ≥65 years of age, respectively). Design: A cross-sectional study of the 2010 Health and Retirement Study (HRS; n=17,912). The following measures were used: (1) count and combinations of CCMM, including (i) chronic conditions (hypertension, arthritis, heart disease, lung disease, stroke, diabetes, cancer, and psychiatric conditions), (ii) functional limitations (upper body limitations, lower body limitations, strength limitations, limitations in activities of daily living, and limitations in instrumental activities of daily living), and (iii) geriatric syndromes (cognitive impairment, depressive symptoms, incontinence, visual impairment, hearing impairment, severe pain, and dizziness); and (2) annualized 2011 Medicare expenditures for HRS participants who were Medicare fee-for-service beneficiaries (n=5,677). Medicaid beneficiaries were also identified based on their self-reported insurance status. Results: No large representations of participants within specific CCMM categories were observed; however, functional limitations and geriatric syndromes were prominently present with higher CCMM counts. Among fee-for-service Medicare beneficiaries aged 50–64 years, 26.7% of the participants presented with ≥10 CCMM, but incurred 48% of the expenditure. In those aged ≥65 years, these percentages were 16.9% and 34.4%, respectively. Conclusion: Functional limitations and geriatric syndromes considerably add to the MM burden in midlife and older adults. This burden is much higher than previously reported.Journal of Comorbidity 2017;7(1):33–4

The Journal of Comorbidity affiliates with the North American Primary Care Research Group

The Journal of Comorbidity is pleased to announce that it has extended its society collaborations by forming another important partnership with the North American Primary Care Research Group (NAPCRG), a renowned multidisciplinary organization for primary care researchers based in North America and beyond. The new partnership reflects an ongoing commitment of both the Journal of Comorbidity and NAPCRG to strengthen and broaden their ties with the primary care community and to foster the dissemination of innovative research in the field of comorbidity and multimorbidity.The partnership marks a celebration of the contribution of NAPCRG and its global members to conducting and reporting high-quality research on comorbidity/multimorbidity over the past 10 years. NAPCRG has been instrumental in growing awareness and developing the field of comorbidity/multimorbidity through various workshops, seminars, and plenaries at its annual meetings held in North America. Furthermore, in 2007, NAPCRG helped organize a meeting funded by the Canadian Institutes of Health on the theme of multimorbidity; attended by over 30 participants from eight countries, this led to the creation of the International Research Community on Multimorbidity (IRCMo) [1]. IRCMo now has almost 1,000 subscribers who are connected through a blog that showcases the most recent developments and publications on comorbidity/multimorbidity research. IRCMo also publishes regular updates on publications that are particularly important in terms of capacity building in research. Journal of Comorbidity 2017;7(1):114–11

The Journal of Comorbidity affiliates with the Scottish School of Primary Care

The Journal of Comorbidity is pleased to announce a new partnership with the Scottish School of Primary Care (SSPC). The SSPC is a virtual school comprising all Scottish academic departments with significant primary care research output. This currently includes the Universities of Aberdeen, Dundee, Edinburgh, Glasgow, Stirling, and St. Andrew’s. This is the second important partnership that the journal has formed to strengthen ties with professional primary care networks with an interest in comorbidity and multimorbidity research. It is anticipated that this new collaboration will increase the journal’s reach and help cultivate research, discussion, and knowledge about comorbidity and multimorbidity.The Scottish School of Primary CareSince its inception in 2000, the SSPC has established a reputation for research excellence, attracting new research funding to Scottish universities. The school aims to support the development of a sustainable, equitable, high-quality primary care service that meets the needs of the people of Scotland. Working towards this vision, the SSPC’s current strategic objectives are to:Inform key stakeholders by collating relevant available national and international evidence, as well as actively contributing to the growing evidence baseSupport the continuing growth of academic primary care in ScotlandPromote Scottish academic primary care internationally.Journal of Comorbidity 2017;7(1):112–11