Multimorbidity and comorbidity in the Dutch population - data from general practices

<p>Abstract</p> <p>Background</p> <p>Multimorbidity is increasingly recognized as a major public health challenge of modern societies. However, knowledge about the size of the population suffering from multimorbidity and the type of multimorbidity is scarce. The objective of this study was to present an overview of the prevalence of multimorbidity and comorbidity of chronic diseases in the Dutch population and to explore disease clustering and common comorbidities.</p> <p>Methods</p> <p>We used 7 years data (2002–2008) of a large Dutch representative network of general practices (212,902 patients). Multimorbidity was defined as having two or more out of 29 chronic diseases. The prevalence of multimorbidity was calculated for the total population and by sex and age group. For 10 prevalent diseases among patients of 55 years and older (N = 52,014) logistic regressions analyses were used to study disease clustering and descriptive analyses to explore common comorbid diseases.</p> <p>Results</p> <p>Multimorbidity of chronic diseases was found among 13% of the Dutch population and in 37% of those older than 55 years. Among patients over 55 years with a specific chronic disease more than two-thirds also had one or more other chronic diseases. Most disease pairs occurred more frequently than would be expected if diseases had been independent. Comorbidity was not limited to specific combinations of diseases; about 70% of those with a disease had one or more extra chronic diseases recorded which were not included in the top five of most common diseases.</p> <p>Conclusion</p> <p>Multimorbidity is common at all ages though increasing with age, with over two-thirds of those with chronic diseases and aged 55 years and older being recorded with multimorbidity. Comorbidity encompassed many different combinations of chronic diseases. Given the ageing population, multimorbidity and its consequences should be taken into account in the organization of care in order to avoid fragmented care, in medical research and healthcare policy.</p

Chronic obstructive pulmonary disease and comorbidities:a large cross-sectional study in primary care

Background: Chronic obstructive pulmonary disease (COPD) is common, and a major cause of morbidity and mortality worldwide. Recent studies suggest that comorbidities of COPD increase the risk of hospitalisation, polypharmacy, and mortality, but their estimated prevalence varies widely in the literature. Aim: To evaluate the prevalence of 38 physical and mental health comorbidities in people with COPD, and compare findings with those for people without COPD in a large nationally representative dataset. Design and setting: A cross-sectional data analysis on 1 272 685 adults in Scotland from 314 primary care practices. Method Data: on COPD, along with 31 physical and seven mental health comorbidities, were extracted. The prevalence of comorbidities was compared between people who did, and did not, have COPD, standardised by age, sex, and socioeconomic deprivation. Results: From the total sample, 51 928 patients had COPD (4.1%). Of these, 86.0% had at least one comorbidity, compared with 48.9% of people without COPD. Of those with COPD, 22.3% had ≥5 comorbid conditions compared with 4.9% of those who did not have COPD (adjusted odds ratio 2.63, 95% confidence interval = 2.56 to 2.70). In total, 29 of the 31 physical conditions and six of the seven mental health conditions were statistically significantly more prevalent in people who had COPD than those who did not. Conclusion: Patients with COPD have extensive associated comorbidities. There is a real need for guidelines and health care to reflect this complexity, including how to detect those common comorbidities that relate to both physical and mental health, and how best to manage them. Primary care, which is unique in terms of offering expert generalist care, is best placed to provide this integrated approach

Bi-directional association between depression and HF: An electronic health records-based cohort study.

To determine whether a bi-directional relationship exists between depression and HF within a single population of individuals receiving primary care services, using longitudinal electronic health records (EHRs). This retrospective cohort study utilized EHRs for adults who received primary care services within a large healthcare system in 2006. Validated EHR-based algorithms identified 10,649 people with depression (depression cohort) and 5,911 people with HF (HF cohort) between January 1, 2006 and December 31, 2018. Each person with depression or HF was matched 1:1 with an unaffected referent on age, sex, and outpatient service use. Each cohort (with their matched referents) was followed up electronically to identify newly diagnosed HF (in the depression cohort) and depression (in the HF cohort) that occurred after the index diagnosis of depression or HF, respectively. The risks of these outcomes were compared (vs. referents) using marginal Cox proportional hazard models adjusted for 16 comorbid chronic conditions. 2,024 occurrences of newly diagnosed HF were observed in the depression cohort and 944 occurrences of newly diagnosed depression were observed in the HF cohort over approximately 4-6 years of follow-up. People with depression had significantly increased risk for developing newly diagnosed HF (HR 2.08, 95% CI 1.89-2.28) and people with HF had a significantly increased risk of newly diagnosed depression (HR 1.34, 95% CI 1.17-1.54) after adjusting for all 16 comorbid chronic conditions. These results provide evidence of a bi-directional relationship between depression and HF independently of age, sex, and multimorbidity from chronic illnesses

Blood pressure management in type 2 diabetes: integrating clinical trials and genetic data

Background: Blood pressure lowering is an established strategy for preventing microvascular and macrovascular complications of diabetes, but its role in the prevention of diabetes itself is unclear. On the other hand, controversy exists as to whether the threshold of blood pressure for initiation of antihypertensive therapy should differ between people with and without type 2 diabetes. I aimed to integrate individual participant data from major randomised controlled trials and genetic data to fill these knowledge gaps. Objectives: This thesis sought to examine three main objectives: to investigate the effect of pharmacological blood pressure-lowering on the risk of new-onset type 2 diabetes; to investigate the separate effects of blood pressure-lowering drug classes on the risk of new-onset type 2 diabetes; to investigate the effect of pharmacological blood pressure-lowering treatment for the prevention of major cardiovascular disease in persons with and without type 2 diabetes. Methods: For the first and second objectives, I conducted a one-stage individual participant-level data meta-analysis of major randomised controlled trials using data from the Blood Pressure Lowering Treatment Trialists' Collaboration (BPLTTC). Analyses were complemented with Mendelian randomisation studies using naturally randomised genetic variants associated with systolic blood pressure and genetic variants in the gene that encodes the therapeutic targets of each drug class. For the third objective, I used one-stage individual participant-level data meta-analysis using the BPLTTC dataset. I expressed the treatment effect per 5 mmHg reduction in systolic blood pressure on the risk of developing a major cardiovascular event as the primary outcome, defined as the first occurrence of fatal or non-fatal stroke or cerebrovascular disease, fatal or non-fatal ischaemic heart disease, or heart failure causing death or requiring hospitalisation. Cox proportional hazard models, stratified by trial, were used to estimate hazard ratios (HRs) separately by type 2 diabetes status at baseline, with further stratification by baseline categories of systolic blood pressure (in 10 mmHg increments from <120 mmHg to ≥170 mmHg). Results: For the first and second objectives, blood pressure-lowering treatment was found to reduce the risk of diabetes by 11% (hazard ratio per 5 mmHg lower systolic blood pressure 0.89 [95% confidence interval [CI] 0.84 to 0.95]). Similarly, in the Mendelian randomisation study, each 5 mmHg genetically influenced lower systolic blood pressure was associated with an 11% lower risk of diabetes (odds ratio 0.89 [95% CI 0.86 to 0.93]). Evidence from genetic data and trials was also consistent in that angiotensin-converting enzyme inhibitors and angiotensin receptor blockers reduced the risk of diabetes, and beta-blockers increased this risk. There was no effect for calcium channel blockers and findings for thiazide diuretics were inconsistent. For the third objective, over 4.2 years median follow-up (IQR 3.0 to 5.0), a 5 mmHg reduction in systolic blood pressure decreased the risk of major cardiovascular events in both groups, but with a weaker relative treatment effect in participants with type 2 diabetes (HR 0.94 [95% CI 0.91 to 0.98]) compared with those without type 2 diabetes (0.89 [0.87 to 0.92]; p for interaction=0.001). However, absolute risk reductions did not differ substantially between people with and without type 2 diabetes (absolute risk reduction -1.54 [95% CI -2.04 to -1.04] in people with diabetes and -1.61 [-1.86 to -1.36] in people without diabetes, p for interaction =1). We found no reliable evidence for heterogeneity of treatment effects by baseline systolic blood pressure in either group. Conclusions: Blood pressure lowering is an effective strategy for the prevention of new-onset type 2 diabetes. Established pharmacological interventions, however, have qualitatively and quantitively different effects on diabetes, likely due to their differing off-target effects, with angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers having the most favourable outcomes. Additionally, although the relative beneficial effects of blood pressure reduction on major cardiovascular events were weaker in participants with type 2 diabetes than in those without, absolute effects were similar. The difference in relative risk reduction was not related to the baseline blood pressure or allocation to different drug classes. Therefore, the adoption of differential blood pressure thresholds, intensities of blood pressure lowering, or drug classes used in people with and without type 2 diabetes is not warranted

Developing a Tool to Support Decisions on Patient Prioritization at Admission to Home Health Care

Background and aims: Millions of Americans are discharged from hospitals to home health every year and about third of them return to hospitals. A significant number of rehospitalizations (up to 60%) happen within the first two weeks of services. Early targeted allocation of services for patients who need them the most, have the potential to decrease readmissions. Unfortunately, there is only fragmented evidence on factors that should be used to identify high-risk patients in home health. This dissertation study aimed to (1) identify factors associated with priority for the first home health nursing visit and (2) to construct and validate a decision support tool for patient prioritization. I recruited a geographically diverse convenience sample of nurses with expertise in care transitions and care coordination to identify factors supporting home health care prioritization. Methods: This was a predictive study of home health visit priority decisions made by 20 nurses for 519 older adults referred to home health. Variables included sociodemographics, diagnosis, comorbid conditions, adverse events, medications, hospitalization in last 6 months, length of stay, learning ability, self-rated health, depression, functional status, living arrangement, caregiver availability and ability and first home health visit priority decision. A combination of data mining and logistic regression models was used to construct and validate the final model. Results: The final model identified five factors associated with first home health visit priority. A cutpoint for decisions on low/medium versus high priority was derived with a sensitivity of 80% and specificity of 57.9%, area under receiver operator curve (ROC) 75.9%. Nurses were more likely to prioritize patients who had wounds (odds ratio [OR]=1.88), comorbid condition of depression (OR=1.73), limitation in current toileting status (OR= 2.02), higher numbers of medications (increase in OR for each medication =1.04) and comorbid conditions (increase in OR for each condition =1.04). Discussion: This dissertation study developed one of the first clinical decision support tools for home health, the PREVENT - Priority for Home Health Visit Tool. Further work is needed to increase the specificity and generalizability of the tool and to test its effects on patient outcomes

Evaluating the role of COPD in patients with heart failure using multiple electronic health data sources

Heart failure (HF) and COPD frequently co-exist. Shared symptoms and risk factors make diagnosis and management difficult and current understanding of the relationship between the diseases is limited. I used several electronic healthcare record (EHR) data sources, from the United States (US) and the United Kingdom (UK) to evaluate the impact of COPD on outcomes in patients with HF. First, I aimed to demonstrate that comorbidity data from EHR can be used to derive meaningful clusters in patients with chronic HF, expecting COPD to be a main driver of this phenotyping endeavour. Second, I compared outcomes (hospitalisation, mortality, healthcare utilisation) in patients with COPD-HF, between left ventricular ejection fraction (LVEF) groups. Third, I pooled data from previously published studies to assess the overall effect of HF management (beta-blockers) on outcomes in COPD. In a fourth study I examined whether COPD was associated with in-hospital mortality and management of patients hospitalised for HF and assessed association with LVEF. Lastly, I investigated whether COPD affected readmission in a population of patients hospitalised for HF. This work provides evidence to suggest that while COPD may not play a major role in determining a HF classification system based on comorbidities only, it affects clinical outcomes in the long-term, particularly for chronic HFpEF patients. Conversely, HF management such as beta-blockers does not appear to worsen outcomes in COPD patients. In the acute setting, coexisting COPD is independently associated with increased in-hospital mortality and decreased HF medication prescription and access to healthcare services amongst patients who survived their first HF admission. Readmission risk is higher amongst those with HF and COPD compared with HF-alone, though the most frequent reason for returning to hospital is still due to a cardiovascular cause.Open Acces

ACCF/AHA 2011 Expert Consensus Document on Hypertension in the Elderly: A Report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents

This document was written with the intent to be a complete reference at the time of publication on the topic of managing hypertension in the elderly. This document has been developed as an expert consensus document by the American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA), in collaboration with the American Academy of Neurology (AAN), the American College of Physicians (ACP), the American Geriatrics Society (AGS), the American Society of Hypertension (ASH), the American Society of Nephrology (ASN), the American Society for Preventive Cardiology (ASPC), the Association of Black Cardiologists (ABC), and the European Society of Hypertension (ESH). Expert consensus documents are intended to inform practitioners, payers, and other interested parties of the opinion of ACCF and document cosponsors concerning evolving areas of clinical practice and/or technologies that are widely available or new to the practice community

Use of non-invasive scores for the estimation of mortality risk in patients with Non-Alcoholic Fatty Liver Disease

Although non-alcoholic fatty liver disease (NAFLD) is rarely associated with the progression to chronic liver disease and its complications, it remains a major public health concern due to its high prevalence and its strong association with the metabolic syndrome (MetS), with an increased risk of cardio-vascular events (CVEs) and with a higher risk of overall and cardio-vascular mortality. In this scenario, holistic treatment of NAFLD may provide prognostic benefit through a reduction of its related overall morbidity and mortality. Hence, the stratification of a patient’s individual risk of cardiovascular disease (CVD), cardiac-specific and overall mortality has a pivotal role for implementing treatment with more aggressive strategies in the high-risk patients. With this study we aim to assess the cardiovascular and liver-related risk in a prospective, observational cohort of consecutive patients with NAFLD who were referred to our Unit for evaluation of liver disease. In these patients, the risk of future cardiovascular events and of liver-related events were estimated using validated risk score calculators and non-invasive tests for fibrosis. Additionally, we aimed to evaluate the potential differences in the estimated cardiovascular and liver-related risks between patients diagnosed with MAFLD and non-MAFLD patients (i.e. patients with steatosis not fulfilling the criteria for a MAFLD diagnosis)

Epidemiology of Colorectal Cancer Comorbidities and Stage at Diagnosis, Survival, and Second Primary Malignancies in Kentucky, 2003-2016

Background: Colorectal cancer (CRC) is the third most common type of cancer and the third most common cause of cancer death among men and women in the United States.1-3 The American Cancer Society estimates that there will be 147,950 new cases of CRC and 53,200 CRC related deaths in the U.S. for the year 2020.3 Kentucky CRC incidence for 2012-2016 was the highest in the nation, and the mortality rate for years 2013-2017 was ranked 5th in the nation.4-6 Risk factors for CRC include lifestyle factors, genetics, and disease status (comorbidities and treatment).2, 7 Diabetes has been found to be the most prevalent comorbidity among CRC patients, and the risk of developing CRC in patients with diabetes is 25% higher than those without diabetes.8, 9 Aim: The purpose of this study is to explore if comorbidities impacts CRC progression, CRC outcomes, and the development of second primary malignancy among CRC patients age 18 and older in Kentucky diagnosed between January 1, 2003 and December 31, 2016. Methods: Two studies were performed using CRC data from Kentucky Cancer Registry, one was a retrospective cohort study and the other was a case control study. There were 20,571 cases included in the cohort study with the primary outcomes was all-cause mortality, CRC mortality, and second primary cancer. There were 18,170 total, 9,085 cases and controls in the second study. This study examined the geographical distribution of late-stage CRC and comorbidities. Results Chapter 3: Logistic regression models show that comorbidities increased the odds of death or late-stage CRC. The Cox proportional hazard models of all-cause and CRC mortalities and second primary show that comorbidities, patient factors, and treatments can be protective or increase the hazards of dying or having a second primary cancer. The Kaplan Meier curve demonstrates the survival of early-stage at diagnosis CRC versus late-stage at diagnosis CRC. Results Chapter 4: The geographical distribution maps of the four positively associated morbidities (electrolyte disorders, liver disease, weight loss, and deficiency anemia) do not demonstrate any patterns resembling the cluster, the comorbidity distribution appears to be random. The map of comorbidities among CRC patients show that a large percentage experience a burden of two or more comorbidities. Conclusion: The results indicate that comorbidities do play a role in the stage of CRC diagnosis, with the data showing greater odds of being diagnosed with early-stage cancer for many of the individual comorbidities. The space-time analysis found a significant high rate cluster of late-stage CRC, however, mapping the distribution of positively associated comorbidities did not demonstrate a pattern matching the cluster. Further research is needed to examine the impact of comorbidities and CRC stage at diagnosis