603 research outputs found

    Patient Complexity: More Than Comorbidity. The Vector Model of Complexity

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    BACKGROUND: The conceptualization of patient complexity is just beginning in clinical medicine. OBJECTIVES: This study aims (1) to propose a conceptual approach to complex patients; (2) to demonstrate how this approach promotes achieving congruence between patient and provider, a critical step in the development of maximally effective treatment plans; and (3) to examine availability of evidence to guide trade-off decisions and assess healthcare quality for complex patients. METHODS/RESULTS: The Vector Model of Complexity portrays interactions between biological, socioeconomic, cultural, environmental and behavioral forces as health determinants. These forces are not easily discerned but exert profound influences on processes and outcomes of care for chronic medical conditions. Achieving congruence between patient, physician, and healthcare system is essential for effective, patient-centered care; requires assessment of all axes of the Vector Model; and, frequently, requires trade-off decisions to develop a tailored treatment plan. Most evidence-based guidelines rarely provide guidance for trade-off decisions. Quality measures often exclude complex patients and are not designed explicitly to assess their overall healthcare. CONCLUSIONS/RECOMMENDATIONS: We urgently need to expand the evidence base to inform the care of complex patients of all kinds, especially for the clinical trade-off decisions that are central to tailoring care. We offer long- and short-term strategies to begin to incorporate complexity into quality measurement and performance profiling, guided by the Vector Model. Interdisciplinary research should lay the foundation for a deeper understanding of the multiple sources of patient complexity and their interactions, and how provision of healthcare should be harmonized with complexity to optimize health

    Multimorbidity: Technical Series on Safer Primary Care

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    Quality of care assessment for people with multimorbidity.

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    Multimorbidity, the simultaneous presence of multiple health conditions in an individual, is an increasingly common phenomenon globally. The systematic assessment of the quality of care delivered to people with multimorbidity will be key to informing the organization of services for meeting their complex needs. Yet, current assessments tend to focus on single conditions and do not capture the complex processes that are required for providing care for people with multimorbidity. We conducted a scoping review on quality of care and multimorbidity in selected databases in June 2018 and identified 87 documents as eligible for review, predominantly original research and reviews from North America, Europe and Australasia and mostly frequently related to primary care settings. We synthesized data qualitatively in terms of perceived challenges, evidence and proposed metrics. Findings reveal that the association between quality of care and multimorbidity is complex and depends on the conditions involved (quality appears to be higher for those with concordant conditions, and lower in the presence of discordant conditions) and the approach used for measuring quality (quality appears to be higher in people with multimorbidity when measured using condition/drug-specific process or intermediate outcome indicators, and worse when using patient-centred reports of experiences of care). People with discordant multimorbidity may be disadvantaged by current approaches to quality assessment, particularly when they are linked to financial incentives. A better understanding of models of care that best meet the needs of this group is needed for developing appropriate quality assessment frameworks. Capturing patient preferences and values and incorporate patients' voices in the form of patient-reported experiences and outcomes of care will be critical towards the achievement of high-performing health systems that are responsive to the needs of people with multimorbidity

    Safer Primary Care: Caring for People with Multiple Conditions

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    Patient complexity: more than comorbidity. the vector model of complexity

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    BACKGROUND: The conceptualization of patient complexity is just beginning in clinical medicine. OBJECTIVES: This study aims (1) to propose a conceptual approach to complex patients; (2) to demonstrate how this approach promotes achieving congruence between patient and provider, a critical step in the development of maximally effective treatment plans; and (3) to examine availability of evidence to guide trade-off decisions and assess healthcare quality for complex patients. METHODS/RESULTS: The Vector Model of Complexity portrays interactions between biological, socioeconomic, cultural, environmental and behavioral forces as health determinants. These forces are not easily discerned but exert profound influences on processes and outcomes of care for chronic medical conditions. Achieving congruence between patient, physician, and healthcare system is essential for effective, patientcentered care; requires assessment of all axes of the Vector Model; and, frequently, requires trade-off decisions to develop a tailored treatment plan. Most evidence-based guidelines rarely provide guidance for trade-off decisions. Quality measures often exclude complex patients and are not designed explicitly to assess their overall healthcare. CONCLUSIONS/RECOMMENDATIONS: We urgently need to expand the evidence base to inform the care of complex patients of all kinds, especially for the clinical trade-off decisions that are central to tailoring care. We offer long-and short-term strategies to begin to incorporate complexity into quality measurement and performance profiling, guided by the Vector Model. Interdisciplinary research should lay the foundation for a deeper understanding of the multiple sources of patient complexity and their interactions, and how provision of healthcare should be harmonized with complexity to optimize health. KEY WORDS: patient complexity; evidence-based care; Vector Model of Complexity

    Comorbidities and Medication Adherence among Older Individuals Living with HIV in the United States

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    The number of people living with HIV (PLWH) ≥65 years old is increasing in the United States (US) as PLWH live longer. In 2015, there were nearly 1 million people living with diagnosed HIV in the US and under 10% were age ≥65. By 2035, the proportion of PLWH in this age group is projected to be 27%. Like the general population of elderly individuals, as they age, PLWH face age-related comorbidities, many of which require routine medical care and daily medications, in addition to daily antiretroviral therapy (ART) for treatment of HIV. Previous research has found that PLWH develop these conditions at higher rates and earlier ages than HIV-negative individuals. Therefore, elderly PLWH are particularly vulnerable to the challenges associated with multimorbidity and polypharmacy, including remaining adherent to their medications. However, in the context of PLWH, “older” has typically been defined as \u3e50 years old, with few studies analyzing PLWH age ≥65, a relevant population given Medicare insurance eligibility in the US. Additionally, there is a dearth of literature focusing on older HIV-positive women and comorbidities. Gaining a better understanding of the non-HIV-related comorbid disease and non-ART comedication burden among PLWH age ≥65 is important because these comorbidities often require care coordination among multiple providers and because comorbidities may negatively impact adherence to ART. With a focus on PLWH aged ≥65 living in the US, the objectives of this dissertation were: (1) to compare the non-HIV disease and non-ART medication burden among PLWH and HIV-negative individuals; (2) to describe patterns of non-HIV condition co-occurrence among PLWH and HIV-negative individuals; and (3) to examine the impact of comorbid disease and comedication burden on ART adherence among PLWH. Using data from 2010 to 2015 in the IBM Watson Health MarketScan® Medicare Supplemental insurance database, I selected PLWH and HIV-negative individuals ≥65 years old based on diagnoses on medical claims and pharmacy claims for ART. Outcomes included common diagnoses and medication classes, prevalence and number of non-HIV conditions, daily non-ART medications, and ART medication adherence (using proportion of days covered (PDC) over a 1-year period, all based on medical and pharmacy claims. To address the first dissertation objective, I examined age-standardized prevalence rates for non-HIV conditions and prevalence ratios (PRs) and fit sex-stratified multivariable generalized linear models for the number of non-HIV conditions and number of daily non-ART medications. For the second dissertation objective, I used latent class analysis to identify classes of individuals based on the presence of non-HIV comorbid conditions. Separate latent class models were fit to cohorts of PLWH, HIV-negative individuals, and HIV-negative individuals matched to the PLWH cohort on demographic characteristics. For the third dissertation objective, I modeled the odds of being adherent to ART (defined as PDC ≥80%) using separate adjusted logistic regression models for PLWH treated with ART with the number of comorbid conditions, the number of comedications, and comorbidity classes as the exposures of interest. Dissertation Objective 1: I assessed non-HIV conditions and daily non-ART medications among 2,359 elderly PLWH and 2,010,513 elderly HIV-negative individuals. PLWH were younger (mean age 71 vs. 76 years) and a larger proportion were men (81% vs. 45%). The most common diagnoses among both HIV-positive and HIV-negative cohorts were hypertension and dyslipidemia. Most non-HIV conditions were more prevalent among PLWH. The largest absolute difference was in anemia (29.6 cases per 100 people vs.11.7) and the largest relative difference was in hepatitis C (PR=22.0). The unadjusted mean number of non-HIV conditions and daily non-ART medications were higher for PLWH (4.61 conditions and 3.79 medications) than HIV-negative individuals (3.94 conditions and 3.41 medications), respectively. In generalized linear models with log link and negative binomial distribution where the outcome was the number of non-HIV conditions, PLWH had significantly more non-HIV conditions than HIV-negative individuals (ratios: men=1.272, [95% CI 1.233-1.312]; women=1.326 [1.245-1.413]). Among those with \u3e0 daily non-ART medications, men with HIV had significantly more non-ART medications than HIV-negative men (ratio=1.178 [1.133-1.226]) in a generalized linear model with log link and gamma distribution where the outcome was number of non-ART medications. Dissertation Objective 2: When conditions with prevalence ≥15% among PLWH were included in latent class models, a 3-class solution was identified for cohorts of PLWH, all HIV-negative individuals, and matched HIV-negative individuals: a sickest class with high probabilities of multiple non-HIV conditions, a class characterized by hypertension and dyslipidemia, and a healthiest class with low probabilities of non-HIV conditions. Nearly 20% of the PLWH were assigned to the sickest class compared to 10.5% of the matched HIV-negative cohort, with PLWH having higher probabilities of specific non-HIV diagnoses, including kidney disease and anemia. Dissertation Objective 3: Lastly, when analyzing the odds of being adherent to ART among 1,644 elderly PLWH with logistic regression models, I found that odds of non-adherence were significantly higher among PLWH with 5-6 comorbidities compared to PLWH with 0-2 comorbidities (adjusted odds ratio [AOR]=1.420 [95% CI 1.035-1.947]). After controlling for the number of comedications, PLWH with 5-6 comorbid conditions (AOR=1.589 [95% CI 1.131-2.232]) and PLWH with ≥7 conditions (AOR=1.528 [95% CI 1.049-2.225]) were 50%-60% more likely to be non-adherent than PLWH with 0-2 conditions. Additionally, PLWH belonging to the hypertension/dyslipidemia/diabetes comorbidity class were more likely to be non-adherent than PLWH in the healthiest class (AOR=1.319 [95% CI 1.047-1.661]). In conclusion, I found that the disease burden associated with aging is substantially higher among PLWH age ≥65 than similarly aged HIV-negative individuals, and that there was a trend of decreasing ART adherence with increasing comorbid disease burden among PLWH. Due to the greater comorbid disease burden, elderly PLWH in the US require additional services and care coordination to effectively manage both HIV and comorbid conditions, particularly those who have a large number of comorbid conditions. Because multimorbidity may have a negative impact of ART adherence, there is a need for interventions focused on primary and secondary prevention of comorbidities and ART adherence among elderly PLWH. Future analyses may include additional analyses with larger samples of older HIV-positive women, assessments of comorbidities and ART medication adherence using other data sources where HIV-specific variables like duration of infection, CD4 and viral load are available, an evaluation of PLWH’s adherence to comedications, such as antidiabetes medications and antihypertensives, and an estimation of the cost impact of comorbid conditions among older PLWH in the US

    Determinants of adverse health outcomes in late-life depression:the role of vitamin D and frailty

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    Older persons with a depression are at risk for vitamin D deficiency and physical health problems. Karen van den Berg studied the relationship between late-life depression, vitamin D, physical frailty and mortality.Among depressed older persons, vitamin D levels did not predict the course of depression. Lower vitamin D levels were associated with an increased risk to become physically frail or die. Specific depression characteristics did not influence the mortality risk, but physical frailty lead to a higher mortality risk. Two years later, vitamin D levels on average were decreased. This decrease was related to a worsening of physical frailty but not to the course of the depressive disorder. In depressed older persons, vitamin D supplementation might have a beneficial effect on the negative somatic health consequences associated with depression. Thus far, few studies, however, have focused on the effect of vitamin D on negative somatic health consequences besides the effect on depression.In clinical practice, adverse somatic health consequences of depression should be assessed and addressed in the treatment plan, since they negatively affect the prognosis. Since low vitamin D levels are common in depressed older persons, we recommend to actively strive for vitamin D supplementation in these population, even though a direct effect of vitamin D on depression is unlikely and the evidence for a link with adverse health consequences is still limited
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