Inverse comorbidity: the power of paradox in the advancement of science

Research on comorbidity and multimorbidity is finally receiving the attention it deserves, particularly considering the magnitude and impact they have on health and the delivery of healthcare [1,2]. Numerous studies have demonstrated that individuals with Down’s syndrome, Parkinson’s disease, schizophrenia, diabetes, anorexia nervosa, Alzheimer’s disease, allergy related diseases, multiple sclerosis or Huntington’s disease (among other health problems) are protected against many forms of cancer, including solid tumors, smoking-related tumors and prostate cancer. This apparent anti-cancer effect, which we have termed inverse cancer comorbidity, has been observed in many serious CNS and immune disorders, and is the subject of active research [3–5].Journal of Comorbidity 2013;3(1):1–3

Withdrawing performance indicators: retrospective analysis of general practice performance under UK Quality and Outcomes Framework

Objectives To investigate the effect of withdrawing incentives on recorded quality of care, in the context of the UK Quality and Outcomes Framework pay for performance scheme. Design Retrospective longitudinal study. Setting Data for 644 general practices, from 2004/05 to 2011/12, extracted from the Clinical Practice Research Datalink. Participants All patients registered with any of the practices over the study period—13 772 992 in total. Intervention Removal of financial incentives for aspects of care for patients with asthma, coronary heart disease, diabetes, stroke, and psychosis. Main outcome measures Performance on eight clinical quality indicators withdrawn from a national incentive scheme: influenza immunisation (asthma) and lithium treatment monitoring (psychosis), removed in April 2006; blood pressure monitoring (coronary heart disease, diabetes, stroke), cholesterol concentration monitoring (coronary heart disease, diabetes), and blood glucose monitoring (diabetes), removed in April 2011. Multilevel mixed effects multiple linear regression models were used to quantify the effect of incentive withdrawal. Results Mean levels of performance were generally stable after the removal of the incentives, in both the short and long term. For the two indicators removed in April 2006, levels in 2011/12 were very close to 2005/06 levels, although a small but statistically significant drop was estimated for influenza immunisation. For five of the six indicators withdrawn from April 2011, no significant effect on performance was seen following removal and differences between predicted and observed scores were small. Performance on related outcome indicators retained in the scheme (such as blood pressure control) was generally unaffected. Conclusions Following the removal of incentives, levels of performance across a range of clinical activities generally remained stable. This indicates that health benefits from incentive schemes can potentially be increased by periodically replacing existing indicators with new indicators relating to alternative aspects of care. However, all aspects of care investigated remained indirectly or partly incentivised in other indicators, and further work is needed to assess the generalisability of the findings when incentives are fully withdrawn

Multimorbidity and comorbidity of chronic diseases among the senior Australians: prevalence and patterns

Understanding patterns and identifying common clusters of chronic diseases may help policymakers, researchers, and clinicians to understand the needs of the care process better and potentially save both provider and patient time and cost. However, only limited research has been conducted in this area, and ambiguity remains as those limited previous studies used different approaches to identify common clusters and findings may vary with approaches. This study estimates the prevalence of common chronic diseases and examines co-occurrence of diseases using four approaches: (i) identification of the most occurring pairs and triplets of comorbid diseases; performing (ii) cluster analysis of diseases, (iii) principal component analysis, and (iv) latent class analysis. Data were collected using a questionnaire mailed to a cross-sectional sample of senior Australians, with 4574 responses. Eighty-two percent of respondents reported having at least one chronic disease and over 52% reported having at least two chronic diseases. Respondents suffering from any chronic diseases had an average of 2.4 comorbid diseases. Three defined groups of chronic diseases were identified: (i) asthma, bronchitis, arthritis, osteoporosis and depression; (ii) high blood pressure and diabetes; and (iii) cancer, with heart disease and stroke either making a separate group or "attaching" themselves to different groups in different analyses. The groups were largely consistent across the approaches. Stability and sensitivity analyses also supported the consistency of the groups. The consistency of the findings suggests there is co-occurrence of diseases beyond chance, and patterns of co-occurrence are important for clinicians, patients, policymakers and researchers. Further studies are needed to provide a strong evidence base to identify comorbid groups which would benefit from appropriate guidelines for the care and management of patients with particular disease clusters.This work was funded by the National Health and Medical Research Council ID (402793, 2006). The Australian Primary Health Care Research Institute is funded by the Australian Government Department of Health and Ageing as part of its Primary Health Care Research Evaluation and Development (PHCRED) Strategy

Routine care provided by specialists to children and adolescents in the United States (2002-2006).

BACKGROUND: Specialist physicians provide a large share of outpatient health care for children and adolescents in the United States, but little is known about the nature and content of these services in the ambulatory setting. Our objective was to quantify and characterize routine and co-managed pediatric healthcare as provided by specialists in community settings. METHODS: Nationally representative data were obtained from the National Ambulatory Medical Care Survey for the years 2002-2006. We included office based physicians (excluding family physicians, general internists and general pediatricians), and a representative sample of their patients aged 18 or less. Visits were classified into mutually exclusive categories based on the major reason for the visit, previous knowledge of the health problem, and whether the visit was the result of a referral. Primary diagnoses were classified using Expanded Diagnostic Clusters. Physician report of sharing care for the patient with another physician and frequency of reappointments were also collected. RESULTS: Overall, 41.3% out of about 174 million visits were for routine follow up and preventive care of patients already known to the specialist. Psychiatry, immunology and allergy, and dermatology accounted for 54.5% of all routine and preventive care visits. Attention deficit disorder, allergic rhinitis and disorders of the sebaceous glands accounted for about a third of these visits. Overall, 73.2% of all visits resulted in a return appointment with the same physician, in half of all cases as a result of a routine or preventive care visit. CONCLUSION: Ambulatory office-based pediatric care provided by specialists includes a large share of non referred routine and preventive care for common problems for patients already known to the physician. It is likely that many of these services could be managed in primary care settings, lessening demand for specialists and improving coordination of care.RIGHTS : This article is licensed under the BioMed Central licence at http://www.biomedcentral.com/about/license which is similar to the 'Creative Commons Attribution Licence'. In brief you may : copy, distribute, and display the work; make derivative works; or make commercial use of the work - under the following conditions: the original author must be given credit; for any reuse or distribution, it must be made clear to others what the license terms of this work are

Time's up. Descriptive epidemiology of multi-morbidity and time spent on health related activity by older Australians: a time use survey

Most Western health systems remain single illness orientated despite the growing prevalence of multi-morbidity. Identifying how much time people with multiple chronic conditions spend managing their health will help policy makers and health service providers make decisions about areas of patient need for support. This article presents findings from an Australian study concerning the time spent on health related activity by older adults (aged 50 years and over), most of whom had multiple chronic conditions. A recall questionnaire was developed, piloted, and adjusted. Sampling was undertaken through three bodies; the Lung Foundation Australia (COPD sub-sample), National Diabetes Services Scheme (Diabetes sub-sample) and National Seniors Australia (Seniors sub-sample). Questionnaires were mailed out during 2011 to 10,600 older adults living in Australia. 2540 survey responses were received and analysed. Descriptive analyses were completed to obtain median values for the hours spent on each activity per month. The mean number of chronic conditions was 3.7 in the COPD sub-sample, 3.4 in the Diabetes sub-sample and 2.0 in the NSA sub-sample. The study identified a clear trend of increased time use associated with increased number of chronic conditions. Median monthly time use was 5-16 hours per month overall for our three sub-samples. For respondents in the top decile with five or more chronic conditions the median time use was equivalent to two to three hours per day, and if exercise is included in the calculations, respondents spent from between five and eight hours per day: an amount similar to full-time work. Multi-morbidity imposes considerable time burdens on patients. Ageing is associated with increasing rates of multi-morbidity. Many older adults are facing high demands on their time to manage their health in the face of decreasing energy and mobility. Their time use must be considered in health service delivery and health system reform.This work was funded by the National Health and Medical Research Council ID (402793, 2006)

Harnessing ChatGPT for thematic analysis: Are we ready?

ChatGPT is an advanced natural language processing tool with growing applications across various disciplines in medical research. Thematic analysis, a qualitative research method to identify and interpret patterns in data, is one application that stands to benefit from this technology. This viewpoint explores the utilization of ChatGPT in three core phases of thematic analysis within a medical context: 1) direct coding of transcripts, 2) generating themes from a predefined list of codes, and 3) preprocessing quotes for manuscript inclusion. Additionally, we explore the potential of ChatGPT to generate interview transcripts, which may be used for training purposes. We assess the strengths and limitations of using ChatGPT in these roles, highlighting areas where human intervention remains necessary. Overall, we argue that ChatGPT can function as a valuable tool during analysis, enhancing the efficiency of the thematic analysis and offering additional insights into the qualitative data.Comment: 23 pages, 7 figures, 3 tables, 1 textbo

Association of self-rated health with multimorbidity, chronic disease and psychosocial factors in a large middle-aged and older cohort from general practice: a cross-sectional study.

BACKGROUND: The prevalence of coexisting chronic conditions (multimorbidity) is rising. Disease labels, however, give little information about impact on subjective health and personal illness experience. We aim to examine the strength of association of single and multimorbid physical chronic diseases with self-rated health in a middle-aged and older population in England, and to determine whether any association is mediated by depression and other psychosocial factors. METHODS: 25 268 individuals aged 39 to 79 years recruited from general practice registers in the European Prospective Investigation of Cancer (EPIC-Norfolk) study, completed a survey including self-rated health, psychosocial function and presence of common physical chronic conditions (cancer, stroke, heart attack, diabetes, asthma/bronchitis and arthritis). Logistic regression models determined odds of "moderate/poor" compared to "good/excellent" health by condition and number of conditions adjusting for psychosocial measures. RESULTS: One-third (8252) reported one, around 7.5% (1899) two, and around 1% (194) three or more conditions. Odds of "moderate/poor" self-rated health worsened with increasing number of conditions (one (OR = 1.3(1.2-1.4)) versus three or more (OR = 3.4(2.3-5.1)), and were highest where there was comorbidity with stroke (OR = 8.7(4.6-16.7)) or heart attack (OR = 8.5(5.3-13.6)). Psychosocial measures did not explain the association between chronic diseases and multimorbidity with self-rated health.The relationship of multimorbidity with self-rated health was particularly strong in men compared to women (three or more conditions: men (OR = 5.2(3.0-8.9)), women OR = 2.1(1.1-3.9)). CONCLUSIONS: Self-rated health provides a simple, integrative patient-centred assessment for evaluation of illness in the context of multiple chronic disease diagnoses. Those registering in general practice in particular men with three or more diseases or those with cardiovascular comorbidities and with poorer self-rated health may warrant further assessment and intervention to improve their physical and subjective health.EPIC-Norfolk is supported by programme grants from Medical Research Council UK (G9502233, G0300128) and Cancer Research UK (C865/A2883), with additional support from the European Union, Stroke Association, Research into Ageing, British Heart Foundation, Department of Health and Wellcome Trust.This is the final version. It was first published by BioMed Central at http://www.biomedcentral.com/1471-2296/15/18

A primary care research agenda for multiple long-term conditions:A Delphi study

BackgroundMultiple long-term conditions (MLTC, multimorbidity) has been identified as a priority research topic, globally. Research priorities from the perspectives of patients and research funders have been described. Although most care for MLTC is delivered in primary care, the priorities of academic primary care have not been identified. AimTo identify and prioritise the academic primary care research agenda for MLTC.Design and SettingThree-phase study with primary care MLTC researchers from the UK and other high-income countries.Method(i) Open-ended survey question; (ii) face-to-face workshop to elaborate questions with researchers from the UK and Ireland; (iii) and a two-round Delphi consensus survey with international multimorbidity researchers.ResultsTwenty-five primary care researchers responded to the initial open-ended survey and generated 84 potential research questions. In the subsequent workshop discussion (18 participants), this list was reduced to 31 questions. The long list of 31 research questions was included in round one of the Delphi; 27 of the 50 (54%) round one and 24 of the 27 to round two (89%) invitees took part in the Delphi. Ten questions reached final consensus. These focused broadly on addressing complexity of the patient group with (a) development of new models of care for multimorbidity, (b) methods and data development.ConclusionThese high priority research questions offer funders and researchers a basis upon which to build future grant calls and research plans. Addressing complexity in our research is needed to inform improvements in our systems of care and for prevention.<br/

Maximising the impact of patient-reported outcome assessment for patients and society

This is the final version. Available on open access from BMJ Publishing Group via the DOI in this recordOver the past decade we have seen a global rise in the involvement of patients in coproducing research and decisions about their health and care. “Measuring what matters to patients” is recognised as central to improving patient care and service delivery, but patients need to be involved in deciding what to measure and how.1 One way to measure what matters is using patient reported outcome measures (PROMs), which are questionnaires completed by patients to assess the effects of disease or treatment (or both) on symptoms, functioning, and health related quality of life from their perspective. PROM data can be used to inform health technology assessment, pharmaceutical labelling claims, health policy and service improvement, and can support communication between patients and healthcare professionals.23 Here we discuss the current applications and potential benefits of PROMs in healthcare and challenges that reduce their potential to drive improvements in patient care. We focus on recent developments in the use of PROMs and consider strategies for efficient PROM data collection to maximise benefits for patients and society.National Institute for Health Research (NIHR

Quality after the QOF? Before dismantling it, we need a redefined measure of ‘quality’

This is the author accepted manuscript. The final version is available from Royal College of General Practitioners via the DOI in this record.n/aNational Institute for Health Research (NIHR