Social disparities in the prevalence of multimorbidity:A register-based population study

Abstract Background Prevalences of multimorbidity vary between European studies and several methods and definitions are used. In this study we examine the prevalence of multimorbidity in relation to age, gender and educational attainment and the association between physical and mental health conditions and educational attainment in a Danish population. Methods A cross-sectional design was used to study the prevalence of multimorbidity, defined as two or more chronic conditions, and of comorbid physical and mental health conditions across age groups and educational attainment levels among 1,397,173 individuals aged 16 years and older who lived in the Capital Region of Denmark on January 1st, 2012. After calculating prevalence, odds ratios for multimorbidity and mental health conditions were derived from logistic regression on gender, age, age squared, education and number of physical conditions (only for odds ratios for mental health conditions). Odds ratios for having multimorbidity and mental health conditions for each variable were adjusted for all other variables. Results Multimorbidity prevalence was 21.6%. Half of the population aged 65 and above had multimorbidity, and prevalence was inversely related to educational attainment: 26.9% (95% CI, 26.8–26.9) among those with lower secondary education versus 13.5% (95% CI, 13.5–13.6) among people with postgraduate education. Adjusted odds ratios for multimorbidity were 0.50 (95% CI, 0.49–0.51) for people with postgraduate education, compared to people with lower secondary education. Among all population members, 4.9% (95% CI, 4.9–4.9) had both a physical and a mental health condition, a proportion that increased to 22.6% of people with multimorbidity. Physical and mental health comorbidity was more prevalent in women (6.33%; 95% CI, 6.3–6.4) than men (3.34%; 95% CI, 3.3–3.4) and approximately 50 times more prevalent among older persons than younger ones. Physical and mental health comorbidity was also twice as prevalent among people with lower secondary education than among those with postgraduate education. The presence of a mental health condition was strongly associated with the number of physical conditions; those with five or more physical conditions had an adjusted odds ratio for a mental health condition of 3.93 (95% CI, 3.8–4.1), compared to those with no physical conditions. Conclusion Multimorbidity prevalence and patterns in the Danish population are comparable to those of other European populations. The high prevalence of mental and physical health conditions highlights the need to ensure that healthcare systems deliver care that takes physical and mental comorbidity into account. Further, the higher prevalence of multimorbidity among persons with low educational attainment emphasizes the importance of having a health care system providing care that is beneficial to all regardless of socioeconomic status

Integration of healthcare rehabilitation in chronic conditions

Introduction: Quality of care provided to people with chronic conditions does not often fulfil standards of care in Denmark and in other countries. Inadequate organisation of healthcare systems has been identified as one of the most important causes for observed performance inadequacies, and providing integrated healthcare has been identified as an important organisational challenge for healthcare systems. Three entities—Bispebjerg University Hospital, the City of Copenhagen, and the GPs in Copenhagen—collaborated on a quality improvement project focusing on integration and implementation of rehabilitation programmes in four conditions. Description of care practice: Four multidisciplinary rehabilitation intervention programmes, one for each chronic condition: chronic obstructive pulmonary disease, type 2 diabetes, chronic heart failure, and falls in elderly people were developed and implemented during the project period. The chronic care model was used as a framework for support of implementing and integration of the four rehabilitation programmes. Conclusion and discussion: The chronic care model provided support for implementing rehabilitation programmes for four chronic conditions in Bispebjerg University Hospital, the City of Copenhagen, and GPs' offices. New management practices were developed, known practices were improved to support integration, and known practices were used for implementation purposes. Several barriers to integrated care were identified

Quality of care for people with multimorbidity:a case series

Abstract Background Multimorbidity is becoming increasingly prevalent and presents challenges for healthcare providers and systems. Studies examining the relationship between multimorbidity and quality of care report mixed findings. The purpose of this study was to investigate quality of care for people with multimorbidity in the publicly funded healthcare system in Denmark. Methods To investigate the quality of care for people with multimorbidity different groups of clinicians from the hospital, general practice and the municipality reviewed records from 23 persons with multimorbidity and discussed them in three focus groups. Before each focus group, clinicians were asked to review patients’ medical records and assess their care by responding to a questionnaire. Medical records from 2013 from hospitals, general practice, and health centers in the local municipality were collected and linked for the 23 patients. Further, two clinical pharmacologists reviewed the appropriateness of medications listed in patient records. Results The review of the patients’ records conducted by three groups of clinicians revealed that around half of the patients received adequate care for the single condition which prompted the episode of care such as a hospitalization, a visit to an outpatient clinic or the general practitioner. Further, the care provided to approximately two-thirds of the patients did not take comorbidities into account and insufficiently addressed more diffuse symptoms or problems. The review of the medication lists revealed that the majority of the medication lists contained inappropriate medications and that there were incongruity in medication listed in the primary and secondary care sector. Several barriers for providing high quality care were identified. These included relative short consultation times in general practice and outpatient clinics, lack of care coordinators, and lack of shared IT-system proving an overview of the treatment. Conclusions Our findings reveal quality of care deficiencies for people with multimorbidity. Suggestions for care improvement for people with multimorbidity includes formally assigned responsibility for care coordination, a change in the financial incentive structure towards a system rewarding high quality care and care focusing on prevention of disease exacerbation, as well as implementing shared medical record systems

Older people’s perception of and coping with falling, and motivation for fall-prevention initiative

Formål: Formålet var at beskrive variationen i ældres opfattelse af at falde, hvordan ældre håndterede fald, samt hvad der påvirkede ældres motivation til at deltage i faldforebyggende tiltag med henblik på at kunne målrette fremtidige indsatser. Metode: Der blev foretaget en kvalitativ interviewundersøgelse med 14 ældre mennesker over 65 år som efter et fald henvendte sig på en skadestue på et universitetshospital i Danmark. Fænomenografi blev anvendt som analysemetode. Resultater: Der blev dannet fem beskrivende kategorier med tilsammen 15 underkategorier. De fem kategorier var: Følelsesmæssig opfattelse af at falde; at falde har konsekvenser; tager hånd om situationen; støtte fra omgivelserne; og motivation og demotivation.Undersøgelsen viste variation i ældres opfattelse af at falde. De ældre accepterede at falde fordi de var blevet ældre. Opfattelsen var, at fald både var flovt og pinligt og havde en forklaring. Nogle ældre oplevede frygten for at falde som dominerende. De ældre opfattede ikke fald som en risikofaktor, der skulle tages hånd om, men håndterede situationen ved at begrænse deres bevægemuligheder eller ved at fravælge aktiviteter. Hvis kravene oversteg de ældres ressourcer, søgte de hjælp fra de pårørende eller den praktiserende læge. De ældre fik støtte, anerkendelse og accept til at foretage valgene af omgivelserne. De ældre blev motiveret af forhold, som autonomi, kompetence og sociale relationer og foretrak aktiviteter, der spredte glæde og nydelse og helst i sociale sammenhænge. De ældre værnede om deres identitet med at ville være medbestemmende om, hvad de deltog i, men mødte forhold i omgivelserne, som var hæmmende for deres motivation. Konklusion: Fremtidige faldforebyggende tiltag skal målrettes ældres behov og tage højde for, at der ikke er én måde men mange måder at opfatte fald på, og at ældre i høj grad selv klarer at håndtere fald, men at de valgte strategier, ikke nødvendigvis er de mest hensigtsmæssige. De ældres netværk og den praktiserende læge kan med fordel spille en aktiv rolle i forbindelse med faldforebyggelse. Ved planlægningen af faldforebyggende interventioner skal der tages hensyn til, at ældres motivation påvirkes af, i hvilken omfang programmerne understøtter de ældres behov for autonomi, kompetence og sociale relationer.Aim: This study aimed to describe variations in elderly people’s perceptions of falling, and how they coped with falls. To target future initiatives to needs of the elderly, we also sought to determine what motivated them to participate in fall-prevention initiatives. Method: We collected data using semi-structured interviews with 14 elderly individuals (65 years +) who had contacted the emergency ward at a university hospital in Denmark. We analyzed the data using a phenomenographic approach that focused on describing varying perceptions by the elderly on the phenomenon of “falling.” Results: Five categories and 15 subcategories emerged from the interviews. The five main categories included emotional perceptions of falling; falling has consequences; handling the situation; support from the social network; motivation and demotivation. The study showed that older people’s perceptions of falling vary. Individuals accepted falling because they had become older. Falls were embarrassing and could be explained. The fear of falling was the foremost concern of some individuals. The elderly did consider falls a meaningful risk factor, but coped by restricting movements or dropping activities to prevent falls in the future. If demands exceeded resources, they asked their relatives or the GP for help. The elderly gained support, approval, and acceptance from their social network when deciding which coping strategies to use. The elderly were motivated by autonomy, competence, and relatedness and they preferred activities that increased happiness and enjoyment, preferably in a social atmosphere. The elderly protected their identity self-determining their activities, but they often encountered factors in their surroundings that restricted motivation. Conclusion: Future fall-prevention initiatives must target the needs of the elderly and consider that there are not one but many ways of perceiving falling. Further, the coping strategies that elderly individuals develop are not necessarily convenient. Social networks and the GP can play active roles in encouraging the elderly to participate in fall-prevention initiatives. When planning fall-prevention interventions, one should consider the extent to which such programs support the elderly individual’s need for autonomy, competence, and relatedness, because these factors affect motivation.ISBN 978-91-85721-70-2</p

Involving patients with multimorbidity in service planning: perspectives on continuity and care coordination

Background: The prevalence of multiple comorbid chronic conditions, or multimorbidity, is increasing. Care provided to people with multimorbidity is often fragmented, incomplete, inefficient and ineffective. As part of a research and development project focusing on improving care, we sought to involve patients with multimorbidity in the development process. Objective: To identify opportunities for improving care by understanding how patients from a Danish University Hospital experience care coordination. Design: Qualitative semi-structured interviews with 14 patients with multimorbidity. Results: Patients with multimorbidity described important concerns about care that included: 1) disease-centered, rather than patient-centered, care; 2) lack of attention to comorbidities and patient preferences and needs; and 3) involvement of numerous healthcare providers with limited care coordination. Poor continuity of care resulted in lack of treatment for complex problems such as pain and mental health issues, medication errors, adverse events and a feeling of being lost in the system. Receiving care from generalists (e.g., general practitioners and healthcare professionals at prevention centers) and having a care coordinator seemed to improve patients’ experience of continuity and coordination of care. Suggestions for service improvements when providing care for people with multimorbidity included using care coordinators, longer consultation times, consultations specifically addressing follow-up on prescribed medications and shifting the focus of care from disease states to patients’ overall health status. Conclusions: A need exists for a reorganization of care delivery for people with multimorbidity that focuses on improved care coordination and puts patient preferences at the center of care. Journal of Comorbidity 2016;6(2):95–10