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

A retrospective analysis of health systems in Denmark and Kaiser Permanente

<p>Abstract</p> <p>Background</p> <p>To inform Danish health care reform efforts, we compared health care system inputs and performance and assessed the usefulness of these comparisons for informing policy.</p> <p>Methods</p> <p>Retrospective analysis of secondary data in the Danish Health Care System (DHS) with 5.3 million citizens and the Kaiser Permanente integrated delivery system (KP) with 6.1 million members in California. We used secondary data to compare population characteristics, professional staff, delivery structure, utilisation and quality measures, and direct costs. We adjusted the cost data to increase comparability.</p> <p>Results</p> <p>A higher percentage of KP patients had chronic conditions than did patients in the DHS: 6.3% vs. 2.8% (diabetes) and 19% vs. 8.5% (hypertension), respectively. KP had fewer total physicians and staff compared to DHS, with134 physicians/100,000 individuals versus 311 physicians/100,000 individuals. KP physicians are salaried employees; in contrast, DHS primary care physicians own and run their practices, remunerated by a mixture of capitation and fee-for-service payments, while most specialists are employed at largely public hospitals. Hospitalisation rates and lengths of stay (LOS) were lower in KP, with mean acute admission LOS of 3.9 days versus 6.0 days in the DHS, and, for stroke admissions, 4.2 days versus 23 days. Screening rates also differed: 93% of KP members with diabetes received retinal screening; only 46% of patients in the DHS with diabetes did. Per capita operating expenditures were PPP$1,951 (KP) and PPP$1,845 (DHS).</p> <p>Conclusion</p> <p>Compared to the DHS, KP had a population with more documented disease and higher operating costs, while employing fewer physicians and resources like hospital beds. Observed quality measures also appear higher in KP. However, simple comparisons between health care systems may have limited value without detailed information on mechanisms underlying differences or identifying translatable care improvement strategies. We suggest items for more in-depth analyses that could improve the interpretability of findings and help identify lessons that can be transferred.</p

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

Is the Kaiser Permanente model superior in terms of clinical integration?: a comparative study of Kaiser Permanente, Northern California and the Danish healthcare system

<p>Abstract</p> <p>Background</p> <p>Integration of medical care across clinicians and settings could enhance the quality of care for patients. To date, there is limited data on the levels of integration in practice. Our objective was to compare primary care clinicians' perceptions of clinical integration and three sub-aspects in two healthcare systems: Kaiser Permanente, Northern California (KPNC) and the Danish healthcare system (DHS). Further, we examined the associations between specific organizational factors and clinical integration within each system.</p> <p>Methods</p> <p>Comparable questionnaires were sent to a random sample of primary care clinicians in KPNC (n = 1103) and general practitioners in DHS (n = 700). Data were analysed using multiple logistic regression models.</p> <p>Results</p> <p>More clinicians in KPNC perceived to be part of a clinical integrated environment than did general practitioners in the DHS (OR = 3.06, 95% CI: 2.28, 4.12). Further, more KPNC clinicians reported timeliness of information transfer (OR = 2.25, 95% CI: 1.62, 3.13), agreement on roles and responsibilities (OR = 1.79, 95% CI: 1.30, 2.47) and established coordination mechanisms in place to ensure effective handoffs (OR = 6.80, 95% CI: 4.60, 10.06). None of the considered organizational factors in the sub-country analysis explained a substantial proportion of the variation in clinical integration.</p> <p>Conclusions</p> <p>More primary care clinicians in KPNC reported clinical integration than did general practitioners in the DHS. Focused measures of clinical integration are needed to develop the field of clinical integration and to create the scientific foundation to guide managers searching for evidence based approaches.</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

Perceived Value of eHealth among People Living with Multimorbidity: A Qualitative Study

Background The prevalence of multimorbidity is increasing, creating challenges for patients, healthcare professionals, and healthcare systems. Given that chronic disease management increasingly involves eHealth, it is useful to assess its perceived value among people with multimorbidity. Objective To explore challenges related to multimorbidity and patients’ perspectives on eHealth. Design Ten semi-structured interviews with adults, living with multimorbidity in Copenhagen, Denmark. Interviews focused on patient-experienced challenges, from challenges related to self-management to challenges experienced in the healthcare sector, as well as perceptions of eHealth. During interviews, participants were presented with pictures of different eHealth technologies. Data analysis followed the systematic text condensation approach. Results Participants experienced challenges in their daily lives, e.g. when practicing self-management activities, when navigating the healthcare sector, and when interacting with healthcare professionals. Patient-perceived value of eHealth varied, depending on their burden of illness and treatment: those with a greater burden had more positive perceptions of eHealth, and expressed more intention to use it. Participants with less complex disease patterns and less burdensome treatment regimens were more likely to perceive eHealth as something worthless and undesirable. Participants stressed that eHealth should only be introduced as an optional supplement. Conclusions eHealth can potentially address some patient-experienced challenges related to multimorbidity by promoting self-management, patient-centeredness, and access. However, patients’ needs and preferences vary and eHealth cannot substitute the personal interaction between patient and healthcare professionals. Our findings point to the importance of patient assessment and stratification to ensure appropriate use of eHealth

Maternal-fetal bonding among pregnant women at psychosocial risk: The roles of adult attachment style, prenatal parental reflective functioning, and depressive symptoms.

Pregnancy offers a unique period for initiating preventive parenting interventions. Disturbances in maternal-fetal bonding may indicate suboptimal parenting and a need for intervention. However, more knowledge is needed on the development of maternal-fetal bonding among at-risk groups. The study aim was to examine psychosocial correlates of maternal-fetal bonding among pregnant women identified to be at risk socially and regarding their mental health. The sample consisted of 78 at-risk pregnant women participating in a perinatal intervention study: Godt på Vej Sammen [A Good Start to Life-an Early Cross-sectorial Intervention]. This study was cross-sectional reporting on the baseline characteristics of the participants. In the beginning of the second trimester, participants completed questionnaires assessing maternal-fetal bonding (the Maternal Antenatal Attachment Scale [MAAS]), prenatal parental reflective functioning, adult attachment style, and depressive symptoms. We compared the distribution of MAAS styles with norms from a recent Dutch community sample. In addition, we tested associations between psychosocial variables and the quality and intensity of MAAS scores in regression models and performed Chi-square analyses to assess the association of MAAS styles with psychosocial variables. First, compared to women from a community sample, approximately half of the women in our sample presented lower and suboptimal MAAS scores. Second, insecure avoidant adult attachment style was negatively associated with MAAS intensity, and depressive symptoms were negatively associated with MAAS quality. Third, prenatal parental reflective functioning positively correlated with both quality and intensity of MAAS. Fourth, we found no association between insecure anxious adult attachment style and MAAS scores. Fifth, women with a negative disinterested MAAS style demonstrated the highest avoidant attachment scores, while women with a positively preoccupied MAAS style demonstrated the highest prenatal parental reflective functioning scores. The results suggest that there is a need to differentiate among at-risk pregnant woman and that prenatal screening using the MAAS may help identify those who need preventive parenting interventions and what those interventions should focus on. A main limitation of the study is the lack of a representative group of at-risk pregnant women which limits the generalizability of the study results to all risk groups