Quintí Foguet-Boreu

Prevalence, determinants and patterns of multimorbidity in primary care: a systematic review of observational studies.

Introduction Multimorbidity is a major concern in primary care. Nevertheless, evidence of prevalence and patterns of multimorbidity, and their determinants, are scarce. The aim of this study is to systematically review studies of the prevalence, patterns and determinants of multimorbidity in primary care. Methods Systematic review of literature published between 1961 and 2013 and indexed in Ovid (CINAHL, PsychINFO, Medline and Embase) and Web of Knowledge. Studies were selected according to eligibility criteria of addressing prevalence, determinants, and patterns of multimorbidity and using a pretested proforma in primary care. The quality and risk of bias were assessed using STROBE criteria. Two researchers assessed the eligibility of studies for inclusion (Kappa  = 0.86). Results We identified 39 eligible publications describing studies that included a total of 70,057,611 patients in 12 countries. The number of health conditions analysed per study ranged from 5 to 335, with multimorbidity prevalence ranging from 12.9% to 95.1%. All studies observed a significant positive association between multimorbidity and age (odds ratio [OR], 1.26 to 227.46), and lower socioeconomic status (OR, 1.20 to 1.91). Positive associations with female gender and mental disorders were also observed. The most frequent patterns of multimorbidity included osteoarthritis together with cardiovascular and/or metabolic conditions. Conclusions Well-established determinants of multimorbidity include age, lower socioeconomic status and gender. The most prevalent conditions shape the patterns of multimorbidity. However, the limitations of the current evidence base means that further and better designed studies are needed to inform policy, research and clinical practice, with the goal of improving health-related quality of life for patients with multimorbidity. Standardization of the definition and assessment of multimorbidity is essential in order to better understand this phenomenon, and is a necessary immediate step.

Comparison of the information provided by electronic health records data and a population health survey to estimate prevalence of selected health conditions and multimorbidity

BackgroundHealth surveys (HS) are a well-established methodology for measuring the health status of a population. The relative merit of using information based on HS versus electronic health records (EHR) to measure multimorbidity has not been established. Our study had two objectives: 1) to measure and compare the prevalence and distribution of multimorbidity in HS and EHR data, and 2) to test specific hypotheses about potential differences between HS and EHR reporting of diseases with a symptoms-based diagnosis and those requiring diagnostic testing.MethodsCross-sectional study using data from a periodic HS conducted by the Catalan government and from EHR covering 80% of the Catalan population aged 15 years and older. We determined the prevalence of 27 selected health conditions in both data sources, calculated the prevalence and distribution of multimorbidity (defined as the presence of ≥2 of the selected conditions), and determined multimorbidity patterns. We tested two hypotheses: a) health conditions requiring diagnostic tests for their diagnosis and management would be more prevalent in the EHR; and b) symptoms-based health problems would be more prevalent in the HS data.ResultsWe analysed 15,926 HS interviews and 1,597,258 EHRs. The profile of the EHR sample was 52% women, average age 47 years (standard deviation: 18.8), and 68% having at least one of the selected health conditions, the 3 most prevalent being hypertension (20%), depression or anxiety (16%) and mental disorders (15%). Multimorbidity was higher in HS than in EHR data (60% vs. 43%, respectively, for ages 15-75+, P <0.001, and 91% vs. 83% in participants aged ≥65 years, P <0.001). The most prevalent multimorbidity cluster was cardiovascular. Circulation disorders (other than varicose veins), chronic allergies, neck pain, haemorrhoids, migraine or frequent headaches and chronic constipation were more prevalent in the HS. Most symptomatic conditions (71%) had a higher prevalence in the HS, while less than a third of conditions requiring diagnostic tests were more prevalent in EHR.ConclusionsPrevalence of multimorbidity varies depending on age and the source of information. The prevalence of self-reported multimorbidity was significantly higher in HS data among younger patients; prevalence was similar in both data sources for elderly patients. Self-report appears to be more sensitive to identifying symptoms-based conditions. A comprehensive approach to the study of multimorbidity should take into account the patient perspective.

Impact of multimorbidity: acute morbidity, area of residency and use of health services across the life span in a region of south Europe

BackgroundConcurrent diseases, multiple pathologies and multimorbidity patterns are topics of increased interest as the world’s population ages. To explore the impact of multimorbidity on affected patients and the consequences for health services, we designed a study to describe multimorbidity by sex and life-stage in a large population sample and to assess the association with acute morbidity, area of residency and use of health services.MethodsA cross-sectional study was conducted in Catalonia (Spain). Participants were 1,749,710 patients aged 19+ years (251 primary care teams). Primary outcome: Multimorbidity (≥2 chronic diseases). Secondary outcome: Number of new events of each acute disease. Other variables: number of acute diseases per patient, sex, age group (19–24, 25–44, 45–64, 65–79, and 80+ years), urban/rural residence, and number of visits during 2010.ResultsMultimorbidity was present in 46.8% (95% CI, 46.7%-46.8%) of the sample, and increased as age increased, being higher in women and in rural areas. The most prevalent pair of chronic diseases was hypertension and lipid disorders in patients older than 45 years. Infections (mainly upper respiratory infection) were the most common acute diagnoses. In women, the highest significant RR of multimorbidity vs. non-multimorbidity was found for teeth/gum disease (aged 19–24) and acute upper respiratory infection. In men, this RR was only positive and significant for teeth/gum disease (aged 65–79). The adjusted analysis showed a strongly positive association with multimorbidity for the oldest women (80+ years) with acute diseases and women aged 65–79 with 3 or more acute diseases, compared to patients with no acute diseases (OR ranged from 1.16 to 1.99, p < 0.001). Living in a rural area was significantly associated with lower probability of having multimorbidity. The odds of multimorbidity increased sharply as the number of visits increased, reaching the highest probability in those aged 65–79 years.ConclusionsMultimorbidity is related to greater use of health care services and higher incidence of acute diseases, increasing the burden on primary care services. The differences related to sex and life-stage observed for multimorbidity and acute diseases suggest that further research on multimorbidity should be stratified according to these factors.

Multimorbidity Patterns in Elderly Primary Health Care Patients in a South Mediterranean European Region: A Cluster Analysis

Objective The purpose of this study was to identify clusters of diagnoses in elderly patients with multimorbidity, attended in primary care. Design Cross-sectional study. Setting 251 primary care centres in Catalonia, Spain. Participants Individuals older than 64 years registered with participating practices. Main outcome measures Multimorbidity, defined as the coexistence of 2 or more ICD-10 disease categories in the electronic health record. Using hierarchical cluster analysis, multimorbidity clusters were identified by sex and age group (65–79 and ≥80 years). Results 322,328 patients with multimorbidity were included in the analysis (mean age, 75.4 years [Standard deviation, SD: 7.4], 57.4% women; mean of 7.9 diagnoses [SD: 3.9]). For both men and women, the first cluster in both age groups included the same two diagnoses: Hypertensive diseases and Metabolic disorders. The second cluster contained three diagnoses of the musculoskeletal system in the 65- to 79-year-old group, and five diseases coincided in the ≥80 age group: varicose veins of the lower limbs, senile cataract, dorsalgia, functional intestinal disorders and shoulder lesions. The greatest overlap (54.5%) between the three most common diagnoses was observed in women aged 65–79 years. Conclusion This cluster analysis of elderly primary care patients with multimorbidity, revealed a single cluster of circulatory-metabolic diseases that were the most prevalent in both age groups and sex, and a cluster of second-most prevalent diagnoses that included musculoskeletal diseases. Clusters unknown to date have been identified. The clusters identified should be considered when developing clinical guidance for this population.

Schizophrenia, antipsychotic drugs and cardiovascular risk: Descriptive study in primary care.

European Psychiatry - In Press.Proof corrected by the author Available online since mardi 20 janvier 2015

Impact of multi-morbidity on quality of healthcare and its implications for health policy, research and clinical practice. A scoping review

Abstract The simultaneous presence of multiple conditions in one patient (multi-morbidity) is a key challenge facing healthcare systems globally. It potentially threatens the coordination, continuity and safety of care. In this paper, we report the results of a scoping review examining the impact of multi-morbidity on the quality of healthcare. We used its results as a basis for a discussion of the challenges that research in this area is currently facing. In addition, we discuss its implications for health policy and clinical practice. The review identified 37 studies focussing on multi-morbidity but using conceptually different approaches. Studies focusing on ‘comorbidity’ (i.e. the ‘index disease’ approach) suggested that quality may be enhanced in the presence of synergistic conditions, and impaired by antagonistic or neutral conditions. Studies on ‘multi-morbidity’ (i.e. multiplicity of problems) and ‘morbidity burden’ (i.e. the total severity of conditions) suggested that increasing number of conditions and severity may be associated with better quality of healthcare when measured by process or intermediate outcome indicators, but with worse quality when patient-centred measures are used. However, issues related to the conceptualization and measurement of multi-morbidity (inconsistent across studies) and of healthcare quality (restricted to evaluations for each separate condition without incorporating considerations about multi-morbidity itself and its implications for management) compromised the generalizability of these observations. Until these issues are addressed and robust evidence becomes available, clinicians should apply minimally invasive and patient-centred medicine when delivering care for clinically complex patients. Health systems should focus on enhancing primary care centred coordination and continuity of care.

Patrones de multimorbilidad en adultos jóvenes en Cataluña: un análisis de clústeres

Resumen Objetivo Identificar los patrones de multimorbilidad en pacientes de 19-44 años atendidos en atención primaria en Cataluña en el año 2010. Diseño Estudio descriptivo transversal. Emplazamiento Doscientos cincuenta y un centros de salud. Participantes Fueron 530.798 personas con multimorbilidad de 19-44 años. Mediciones principales La multimorbilidad fue definida como la coexistencia de ≥2 diagnósticos de la Clasificación Internacional de Enfermedades registrados en la historia clínica informatizada. Los patrones de multimorbilidad fueron identificados a través de un análisis jerárquico de clústeres y descritos por sexo y grupos de edad (19-24 y 25-44 años). Resultados De las 882.708 personas de la población inicial, 530.798 (60,1%) presentaron multimorbilidad. La media de edad fue de 33,0 años (DT: 7,0) y el 53,3% fueron mujeres. La multimorbilidad fue más alta en el grupo de 25-44 años respecto al grupo más joven (60,5 vs. 58,1%, p < 0,001), siendo más alta en las mujeres. El clúster más prevalente en todos los estratos estuvo constituido por caries dental, tabaquismo, dorsalgia, resfriado común y otros trastornos de ansiedad. En ambos sexos, en los estratos de 25-44 años apareció el patrón cardiovascular-endocrino-metabólico (obesidad, dislipidemias e hipertensión arterial). Conclusiones La multimorbilidad afecta a más de la mitad de personas entre los 19-44 años de edad. El clúster más prevalente está formado por diagnósticos que agrupan enfermedades comunes (caries dental, resfriado común, tabaquismo, trastornos de ansiedad y dorsalgias). Otro patrón a destacar es el cardiovascular-endocrino-metabólico en el grupo de 25-44. El conocimiento de los patrones de multimorbilidad en adultos jóvenes permitiría un enfoque preventivo.

Comparative analysis of methods for identifying multimorbidity patterns: a study of ‘real-world’ data

Objective The aim was to compare multimorbidity patterns identified with the two most commonly used methods: hierarchical cluster analysis (HCA) and exploratory factor analysis (EFA) in a large primary care database. Specific objectives were: (1) to determine whether choice of method affects the composition of these patterns and (2) to consider the potential application of each method in the clinical setting. Design Cross-sectional study. Diagnoses were based on the 263 corresponding blocks of the International Classification of Diseases version 10. Multimorbidity patterns were identified using HCA and EFA. Analysis was stratified by sex, and results compared for each method. Setting and participants Electronic health records for 408 994 patients with multimorbidity aged 45–64 years in 274 primary health care teams from 2010 in Catalonia, Spain. Results HCA identified 53 clusters for women, with just 12 clusters including at least 2 diagnoses, and 15 clusters for men, all of them including at least two diagnoses. EFA showed 9 factors for women and 10 factors for men. We observed differences by sex and method of analysis, although some patterns were consistent. Three combinations of diseases were observed consistently across sex groups and across both methods: hypertension and obesity, spondylopathies and deforming dorsopathies, and dermatitis eczema and mycosis. Conclusions This study showed that multimorbidity patterns vary depending on the method of analysis used (HCA vs EFA) and provided new evidence about the known limitations of attempts to compare multimorbidity patterns in real-world data studies. We found that EFA was useful in describing comorbidity relationships and HCA could be useful for in-depth study of multimorbidity. Our results suggest possible applications for each of these methods in clinical and research settings, and add information about some aspects that must be considered in standardisation of future studies: spectrum of diseases, data usage and methods of analysis.

Pharmacological control of diabetes and hypertension comorbidity in the elderly: A study of “real world” data

AIMS The study aimed to determine which drug combinations achieve better control in comorbid diabetes and hypertension in a pragmatic sample of primary health care patients. METHODS Cross-sectional study. SETTING 251 primary health care centres in Catalonia, Spain. PARTICIPANTS individuals ≥65 years old with a dual diagnosis of hypertension and diabetes. MAIN OUTCOME MEASURES good control criteria were established as glycated haemoglobin ≤7% and blood pressure <140/90mmHg. Antihypertensive and hypoglycaemic drugs and treatment adherence were analysed in relation to their association with good control. RESULTS 27,637 patients (58.0% women) had hypertension and diabetes and met selection criteria. Mean age was 75.9 years (standard deviation [SD]: 6.7). Both diseases were well controlled simultaneously in 34.2% of patients. The combination of biguanides and diuretics achieved the highest association with good control. Adherence to pharmacological treatment was more difficult in diabetes than in hypertension. Lack of control was associated significantly with non-adherence to treatment, 0-12 PHC visits, obesity and increasing number of diabetes prescriptions. CONCLUSIONS Good control of diabetes and hypertension comorbidity with pharmacological treatment in elderly patients is challenging. Some drug combinations achieved better control than others. The greatest effort should focus on improving the low adherence to diabetes treatment.

Neuroleptic malignant syndrome: a case responding to electroconvulsive therapy plus bupropion

Neuroleptic malignant syndrome (NMS) is a severe motor syndrome occurring as a consequence of neuroleptic treatment. We present a case of a 67-year-old Caucasian woman with a history of a major depressive disorder with psychotic features. During her third hospital admission, symptoms of autonomic instability, hyperpyrexia, severe extrapyramidal side effects, and delirium appeared, suggesting NMS due to concomitant treatment with risperidone and quetiapine, among other drugs. Despite several consecutive pharmacological treatments (lorazepam, bromocriptine and amantadine) and prompt initiation of electroconvulsive therapy (ECT), clinical improvement was observed only after combining bupropion with ECT. The symptoms that had motivated the admission gradually remitted and the patient was discharged home. Bupropion increases dopaminergic activity in both the nucleus accumbens and the prefrontal cortex. Therefore, from a physiopathological standpoint, bupropion has a potential role in treating NMS. However, there is scarce evidence supporting this approach and therefore future cases should be carefully considered.