Predicting declines in physical function in persons with multiple chronic medical conditions: what we can learn from the medical problem list

BACKGROUND: Primary care physicians are caring for increasing numbers of persons with comorbid chronic illness. Longitudinal information on health outcomes associated with specific chronic conditions may be particularly relevant in caring for these populations. Our objective was to assess the effect of certain comorbid conditions on physical well being over time in a population of persons with chronic medical conditions; and to compare these effects to that of hypertension alone. METHODS: We conducted a secondary analysis of 4-year longitudinal data from the Medical Outcomes Study. A heterogeneous population of 1574 patients with either hypertension alone (referent) or one or more of the following conditions: diabetes, coronary artery disease, congestive heart failure, respiratory illness, musculoskeletal conditions and/or depression were recruited from primary and specialty (endocrinology, cardiology or mental health) practices within HMO and fee-for-service settings in three U.S. cities. We measured categorical change (worse vs. same/better) in the SF-36(R) Health Survey physical component summary score (PCS) over 4 years. We used logistic regression analysis to determine significant differences in longitudinal change in PCS between patients with hypertension alone and those with other comorbid conditions and linear regression analysis to assess the contribution of the explanatory variables. RESULTS: Specific diagnoses of CHF, diabetes and/or chronic respiratory disease; or 4 or more chronic conditions, were predictive of a clinically significant decline in PCS. CONCLUSIONS: Clinical recognition of these specific chronic conditions or 4 or more of a list of chronic conditions may provide an opportunity for proactive clinical decision making to maximize physical functioning in these populations

How can I improve patient adherence to prescribed medication?

Two randomized clinical trials have shown that simplified dosing schedules have improved patient adherence to medication as prescribed. Some, but not all, randomized controlled trials show multidimensional interventions can also improve adherence. These interventions include combinations of patient and family education, home monitoring of disease status, and increased convenience of care, such as workplace access. (Grade of Recommendation: B, based on randomized controlled trials

Subjective assessments of comorbidity correlate with quality of life health outcomes: Initial validation of a comorbidity assessment instrument

BACKGROUND: Interventions to improve care for persons with chronic medical conditions often use quality of life (QOL) outcomes. These outcomes may be affected by coexisting (comorbid) chronic conditions as well as the index condition of interest. A subjective measure of comorbidity that incorporates an assessment of disease severity may be particularly useful for assessing comorbidity for these investigations. METHODS: A survey including a list of 25 common chronic conditions was administered to a population of HMO members age 65 or older. Disease burden (comorbidity) was defined as the number of self-identified comorbid conditions weighted by the degree (from 1 to 5) to which each interfered with their daily activities. We calculated sensitivities and specificities relative to chart review for each condition. We correlated self-reported disease burden, relative to two other well-known comorbidity measures (the Charlson Comorbidity Index and the RxRisk score) and chart review, with our primary and secondary QOL outcomes of interest: general health status, physical functioning, depression screen and self-efficacy. RESULTS: 156 respondents reported an average of 5.9 chronic conditions. Median sensitivity and specificity relative to chart review were 75% and 92% respectively. QOL outcomes correlated most strongly with disease burden, followed by number of conditions by chart review, the Charlson Comorbidity Index and the RxRisk score. CONCLUSION: Self-report appears to provide a reasonable estimate of comorbidity. For certain QOL assessments, self-reported disease burden may provide a more accurate estimate of comorbidity than existing measures that use different methodologies, and that were originally validated against other outcomes. Investigators adjusting for comorbidity in studies using QOL outcomes may wish to consider using subjective comorbidity measures that incorporate disease severity

"Call a Teenager… That's What I Do!" - Grandchildren Help Older Adults Use New Technologies: Qualitative Study.

BackgroundAlthough family technical support seems intuitive, there is very little research exploring this topic.ObjectiveThe objective of this study was to conduct a subanalysis of data collected from a large-scale qualitative project regarding older adults' experiences in using health information technology. Specifically, the subanalysis explored older adults' experiences with technology support from family members to inform strategies for promoting older adults' engagement with new health technologies. Although the primary analysis of the original study was theoretically driven, this paper reports results from an inductive, open-coding analysis.MethodsThis is a subanalysis of a major code identified unexpectedly from a qualitative study investigating older adults' use experience of a widespread health technology, the patient portal. A total of 24 older patients (≥65 years) with multiple chronic conditions (Charlson Comorbidity Index >2) participated in focus groups conducted at the patients' primary clinic. While conducting the primary theoretically driven analysis, coders utilized an open-coding approach to ensure important ideas not reflected in the theoretical code book were captured. Open coding resulted in 1 code: family support. This subanalysis further categorized family support by who provided tech support, how tech support was offered, and the opinions of older participants about receiving family tech support.ResultsThe participants were not specifically asked about family support, yet themes around family assistance and encouragement for technology emerged from every focus group. Participants repeatedly mentioned that they called their grandchildren and adult children if they needed help with technology. Participants also reported that family members experienced difficulty when teaching technology use. Family members struggled to explain simple technology tasks and were frustrated by the slow teaching process.ConclusionsThe results suggest that older adults ask their family members, particularly grandchildren, to support them in the use of new technologies. However, family may experience difficulties in providing this support. Older adults will be increasingly expected to use health technologies, and family members may help with tech support. Providers and health systems should consider potential family support and engagement strategies to foster adoption and use among older patients

Challenges in access to health services and its impact on quality of life: a randomised population-based survey within Turkish speaking immigrants in London

<p>Abstract</p> <p>Background and aim</p> <p>There are a significant number of Turkish speaking immigrants living in London. Their special health issues including women's health, mental health, and alcohol and smoking habits has been assessed. The aim of this study was to explore the ongoing challenges in access to health care services and its impact on Quality of Life of immigrants.</p> <p>Material and methods</p> <p>This cross-sectional population-based study was conducted between March and August 2010 with Turkish immigrants (n = 416) living in London. Of these, 308 (74%) were Turkish and 108 (26%) were Turkish Cypriots. All healthy or unhealthy adults of 17-65 years of age were enrolled. A structured questionnaire with 44 items in five subcategories and 26-items WHOQOL BREF were used.</p> <p>Results</p> <p>Mean duration of stay for Turkish Cypriots (26.9 ± 13.9 years) was significantly longer than Turkish immigrants (13.3 ± 7.5) (p < 0.001). Turkish immigrants (n = 108, 36.5%) need interpretation more often when using health services than Turkish Cypriots (n = 16, 15%) (p < 0.001). Multivariate analyses suggested significant effects of older age, non-homeownership, low socioeconomic class, poor access to health services, being ill, poor community integration and being obese on physical well-being and also significant effects of low income and poor community integration on perceived overall Quality of Life (WHOQOL) of the participants.</p> <p>Conclusions</p> <p>The results of this study demonstrate how the health and well-being of members of the Turkish speaking community living in London are affected by social aspects of their lives. Providing culturally competent care and interpretation services and advocacy may improve the accessibility of the health care.</p

Competing risks of cancer mortality and cardiovascular events in individuals with multimorbidity

Background: Cancer patients with cardiovascular and other comorbidities are at concurrent risk of multiple adverse outcomes. However, most treatment decisions are guided by evidence from single-outcome models, which may be misleading for multimorbid patients. Objective: We assessed the interacting effects of cancer, cardiovascular, and other morbidity burdens on the competing outcomes of cancer mortality, serious cardiovascular events, and other-cause mortality. Design: We analyzed a cohort of 6,500 adults with initial cancer diagnosis between 2001 and 2008, SEER 5-year survival ≥26%, and a range of cardiovascular risk factors. We estimated the cumulative incidence of cancer mortality, a serious cardiovascular event (myocardial infarction, coronary revascularization, or cardiovascular mortality), and other-cause mortality over 5 years, and identified factors associated with the competing risks of each outcome using cause-specific Cox proportional hazard models. Results: Following cancer diagnosis, there were 996 (15.3%) cancer deaths, 328 (5.1%) serious cardiovascular events, and 542 (8.3%) deaths from other causes. In all, 4,634 (71.3%) cohort members had none of these outcomes. Although cancer prognosis had the greatest effect, cardiovascular and other morbidity also independently increased the hazard of each outcome. The effect of cancer prognosis on outcome was greatest in year 1, and the effect of other morbidity was greater in individuals with better cancer prognoses. Conclusion: In multimorbid oncology populations, comorbidities interact to affect the competing risk of different outcomes. Quantifying these risks may provide persons with cancer plus cardiovascular and other comorbidities more accurate information for shared decision-making than risks calculated from single-outcome models. Journal of Comorbidity 2014:4(1):29–3

A Core Outcome Set for multimorbidity research (COSmm)

PURPOSE: We aimed to develop a consensus-based set of core outcomes specifically for studies in multimorbidity. METHODS: We undertook a consensus study following the COS-STAR (Core Outcome Set-STAndards for Reporting) guidelines for the design and reporting of core outcome sets. A Delphi panel of experts completed a web-based survey with 2 rounds. Panelists were presented with a range of outcomes that had been identified in previous workshops and a related systematic review. They indicated their level of agreement on whether each outcome should be included in the core set using a 5-point Likert scale, and outcomes reaching a prespecified consensus level were included. RESULTS: Of 30 individuals invited to be panelists, 26 from 13 countries agreed. All 26 completed both rounds of the survey. The Delphi panel reached consensus on 17 outcomes for inclusion in a core outcome set for multimorbidity (COSmm). The highest-ranked outcomes were health-related quality of life, mental health outcomes, and mortality. Other outcomes were grouped into overarching themes of patient-reported impacts and behaviors (treatment burden, self-rated health, self-management behavior, self-efficacy, adherence); physical activity and function (activities of daily living, physical function, physical activity); consultation related (communication, shared decision making, prioritization); and health systems (health care use, costs, quality of health care). CONCLUSIONS: This consensus study involved a wide range of international experts who identified a large number of outcomes for multimorbidity intervention studies. Our results suggest that quality of life, mental health outcomes, and mortality should be regarded as essential core outcomes. Researchers should, however, also consider the full range of outcomes when designing studies to capture important domains in multimorbidity depending on individual study aims and interventions

Systematic review of the effectiveness of community-based self-management interventions among primary care COPD patients

Chronic Lung Disease: Towards effective self-management in primary care Further work is needed to ensure that self-management of chronic lung disease in primary care settings actively improves patients’ quality of life. While self-management is beneficial to patients in secondary care with severe chronic obstructive pulmonary disease (COPD), few studies have examined self-management effectiveness in primary care patients with milder COPD. Kate Jolly at the University of Birmingham, UK, and co-workers identified only 12 studies out of over 12,500 that specifically examined self-management in primary care. Of these, seven were suitable for metanalysis. The team found that community-based interventions to support self-management did not make a significant difference to patients’ perceived quality of life, or in reducing anxiety and depression. They call for further research to identify specific support that will help patients with mild to moderate COPD cope and adapt to the progressive condition