Ulrich Thiem

The Ariadne principles: how to handle multimorbidity in primary care consultations

Multimorbidity is a health issue mostly dealt with in primary care practice. As a result of their generalist and patient-centered approach, long-lasting relationships with patients, and responsibility for continuity and coordination of care, family physicians are particularly well placed to manage patients with multimorbidity. However, conflicts arising from the application of multiple disease oriented guidelines and the burden of diseases and treatments often make consultations challenging. To provide orientation in decision making in multimorbidity during primary care consultations, we developed guiding principles and named them after the Greek mythological figure Ariadne. For this purpose, we convened a two-day expert workshop accompanied by an international symposium in October 2012 in Frankfurt, Germany. Against the background of the current state of knowledge presented and discussed at the symposium, 19 experts from North America, Europe, and Australia identified the key issues of concern in the management of multimorbidity in primary care in panel and small group sessions and agreed upon making use of formal and informal consensus methods. The proposed preliminary principles were refined during a multistage feedback process and discussed using a case example. The sharing of realistic treatment goals by physicians and patients is at the core of the Ariadne principles. These result from i) a thorough interaction assessment of the patient’s conditions, treatments, constitution, and context; ii) the prioritization of health problems that take into account the patient’s preferences – his or her most and least desired outcomes; and iii) individualized management realizes the best options of care in diagnostics, treatment, and prevention to achieve the goals. Goal attainment is followed-up in accordance with a re-assessment in planned visits. The occurrence of new or changed conditions, such as an increase in severity, or a changed context may trigger the (re-)start of the process. Further work is needed on the implementation of the formulated principles, but they were recognized and appreciated as important by family physicians and primary care researchers.Please see related article: http://www.biomedcentral.com/1741-7015/12/222.

Nocturnal hypoxaemia is associated with increased mortality in stable heart failure patients

AIM This study investigated the prognostic value of sleep-disordered breathing (SDB) in a large cohort of patients with heart failure with reduced left ventricular function (HF-REF), with focus on the role of nocturnal hypoxaemia. METHODS This single-centre prospective cohort study enrolled patients with chronic stable HF-REF (NYHA ≥II) receiving guideline-based treatment. Unattended in-hospital polygraphy was performed to determine the apnoea-hypopnoea index (AHI). Pulse oximetry was used to determine hypoxaemic burden [time with oxygen saturation <90% (T90)], and all-cause mortality was recorded. RESULTS Complete data were available for 963 of 1249 patients. At baseline, 58% of patients had moderate-to-severe SDB. The median follow-up was 7.35 years; 480 of 963 (49.8%) patients died. Mortality rate (per 100 person-years) was 8.1 [95% confidence interval (CI) 7.0-9.4] in patients with no or mild SDB, but 12.2 (95% CI 10.9-13.7) in moderate-to-severe SDB. Apnoea-hypopnoea index was significantly associated with time to death from any cause in a simple Cox model [hazard ratio (HR) 1.011, P < 0.001], but was no longer significant after adjustment for confounding factors (HR 1.005, P = 0.085). T90 was significantly (P < 0.001) associated with time to death from any cause even after adjustment for confounding factors. The risk of death increased by 16.1% (95% CI 8.6-24.2) per hour of T90. Five-year survival probabilities for patients in T90 quartiles 1, 2, 3, and 4 were 70, 63, 60, and 50%, respectively. CONCLUSION Hypoxaemic burden was a robust and independent predictor of all-cause mortality in chronic stable HF-REF patients. Whether or not targeting nocturnal hypoxaemia is associated with beneficial effects on mortality in HF-REF patients remains to be determined.

The geriatric management of frailty as paradigm of the end of the disease era

The sustainability of healthcare systems worldwide is threatened by the absolute and relative increase in the number of older persons. The traditional models of care (largely based on a disease-centered approach) are inadequate for a clinical world dominated by older individuals with multiple (chronic) comorbidities and mutually interacting syndromes. There is the need to shift the center of the medical intervention from the disease to the biological age of the individual. Thus, multiple medical specialties have started looking with some interest at concepts of geriatric medicine in order to better face the increased complexity (due to age-related conditions) of their average patient. In this scenario, special interest has been given to frailty, a condition characterized by the reduction of the individuals homeostatic reserves and increased vulnerability to stressors. Frailty may indeed represent the fulcrum to lever for reshaping the healthcare systems in order to make them more responsive to new clinical needs. However, the dissemination of the frailty concept across medical specialties requires a parallel and careful consideration around the currently undervalued role of geriatricians in our daily practice.

Prevalence of anemia in elderly patients in primary care: impact on 5-year mortality risk and differences between men and women

ABSTRACT Background: Increased mortality in patients with anemia has been demonstrated in disabled, seriously ill or hospitalized patients. In industrialized nations with their aging societies, however, elderly but apparently healthy family-physician patients are an important demographic group from a public-health perspective. We therefore set out to evaluate the prevalence of anemia in this group and associations between anemia and 5-year all-cause mortality, adjusted for multiple other established risk factors and chronic diseases. Methods: This was a monitored, prospective cohort study in Germany with 344 representative family physicians who documented, consecutively, elderly patients (aged ≥ 65 years). Extensive fasting plasma parameters were collected at baseline. Anemia at inclusion was defined according to World Health Organization criteria (hemoglobin below 12 g/dl in women and 13 g/dl in men). All participants were followed up for death of any cause for 5.3 years. Results: Among the 6880 individuals, 2905 men and 3975 women, aged 65–95 (mean age 72.5), mild anemia (hemoglobin levels ≥10 g/dl) was found in 6.1% of women and 8.1% of men. Among those patients, 36.1% of anemic men and 15.0% of anemic women died. In a Cox proportional hazards analysis, multiple adjusted for potential confounders including major comorbidities, a near doubling of the 5-year mortality risk in anemic men (hazard ratio [HR] 1.9; 95% confidence interval [CI] 1.5–2.4) was found, while in anemic women there was no risk increase at all (HR 1.1; 95% CI 0.8–1.6). Even if patients with the lowest hemoglobin concentration (<11 g/dl for women, <12 g/dl for men) are singled out for multiple-adjusted analysis, anemia in men was related to a significant mortality risk (HR 3.3; 95% CI 2.1–5.1), but not in women (HR 1.85; 95% CI 0.97–3.53). Conclusion: In typical elderly patients without severe comorbidities, mild anemia was significantly associated with greater mortality in men but not in women. Given the impact of sex on outcomes of older subjects with mild anemia, the current definition of anemia should be adjusted for elderly males towards a higher hemoglobin threshold. Interventional trials will be needed to determine whether a consistent correction of anemia improves mortality of older men.

C-reactive protein, severity of pneumonia and mortality in elderly, hospitalised patients with community-acquired pneumonia

BACKGROUND increasingly, markers of systemic inflammation like C-reactive protein (CRP) levels and white blood count (WBC) are being used for assessing the prognosis of patients with community-acquired pneumonia (CAP). However, their predictive value has not been validated in populations of elderly patients. OBJECTIVE to evaluate the prognostic value of CRP and WBC in comparison with the CURB score and the pneumonia severity index (PSI) in elderly, hospitalised patients with CAP. METHODS the charts of all patients, aged 65 years and older, who were consecutively admitted to the Department of Geriatrics, Marienhospital Herne, Germany, for treatment of CAP between January 2001 and September 2005, were reviewed. CRP, WBC, CURB and PSI were analysed in relation to 30-day mortality. RESULTS in a total of 391 patients, median age 80 years, no association was found between CRP or WBC and mortality. In contrast, the CURB score and PSI were significantly associated with mortality and treatment in the intensive care unit (ICU). CONCLUSION in elderly, hospitalised patients with CAP, admission CRP and WBC are not predictors of the prognosis.

Elderly Patients with Community-Acquired Pneumonia

Community-acquired pneumonia (CAP) is a common infectious disease that still causes substantial morbidity and mortality. Elderly people are frequently affected, and several issues related to care of this condition in the elderly have to be considered. This article reviews current recommendations of guidelines with a special focus on aspects of the care of elderly patients with CAP.The most common pathogen in CAP is still Streptococcus pneumoniae, followed by other pathogens such as Haemophilus influenzae, Mycoplasma pneumoniae, Chlamydophila pneumoniae and Legionella species. Antimicrobial resistance is an increasing problem, especially with regard to macrolide-resistant S. pneumoniae and fluoroquinolone-resistant strains. With regard to β-lactam antibacterials, resistance by H. influenzae and Moraxella catarrhalis is important, as is the emergence of multidrug-resistant Staphylococcus aureus. The main management decisions should be guided by the severity of disease, which can be assessed by validated clinical risk scores such as CURB-65, a tool for measuring the severity of pneumonia based on assessment of confusion, serum urea, respiratory rate and blood pressure in patients aged ≥65 years.For the treatment of low-risk pneumonia, an aminopenicillin such as amoxicillin with or without a β-lactamase inhibitor is frequently recommended. Monotherapy with macrolides is also possible, although macrolide resistance is of concern. When predisposing factors for special pathogens are present, a β-lactam antibacterial combined with a β-lactamase inhibitor, or the combination of a β-lactam antibacterial, a β-lactamase inhibitor and a macrolide, may be warranted. If possible, patients who have undergone previous antibacterial therapy should receive drug classes not previously used.For hospitalized patients with non-severe pneumonia, a common recommendation is empirical antibacterial therapy with an aminopenicillin in combination with a β-lactamase inhibitor, or with fluoroquinolone monotherapy. With proven Legionella pneumonia, a combination of β-lactams with a fluoroquinolone or a macrolide is beneficial. In severe pneumonia, ureidopenicillins with β-lactamase inhibitors, broad-spectrum cephalosporins, macrolides and fluoroquinolones are used. A combination of a broad-spectrum β-lactam antibacterial (e.g. cefotaxime or ceftriaxone), piperacillin/tazobactam and a macrolide is mostly recommended. In patients with a predisposition for Pseudomonas aeruginosa, a combination of piperacillin/tazobactam, cefepime, imipenem or meropenem and levofloxacin or ciprofloxacin is frequently used. Treatment duration of more than 7 days is not generally recommended, except for proven infections with P. aeruginosa, for which 15 days of treatment appears to be appropriate. Further care issues in all hospitalized patients are timely administration of antibacterials, oxygen supply in case of hypoxaemia, and fluid management and dose adjustments according to kidney function.The management of elderly patients with CAP is a challenge. Shifts in antimicrobial resistance and the availability of new antibacterials will change future clinical practice. Studies investigating new methods to detect pathogens, determine the optimal antimicrobial regimen and clarify the duration of treatment may assist in further optimizing the management of elderly patients with CAP.

Prerequisites for a new health care model for elderly people with multimorbidity: the PRISCUS research consortium.

Fragestellung Das gleichzeitige Auftreten oder Vorhandensein mehrerer chronischer Erkrankungen im Sinne einer Multimorbiditat stellt den betroffenen Patienten, seine Angehorigen sowie Arzte und Therapeuten vor grose Herausforderungen. Das Gesundheitssystem wird durch die steigende Zahl Betroffener und ihre komplexen Bedurfnisse, aber auch durch die Vielfalt haufig schlecht koordinierter Interventionen zunehmend belastet. Zur Verbesserung der medizinischen Versorgung bietet sich das fur chronisch Kranke entwickelte „Chronic Care Model“ an. Der Forschungsverbund PRISCUS versucht, die Voraussetzungen fur ein daran orientiertes, neues Versorgungsmodell fur multimorbide, altere Patienten zu schaffen.BackgroundMultimorbidity, the concurrent manifestation or presence of multiple chronic conditions, poses huge challenges to affected patients, their relatives, physicians, and practitioners alike. The growing number of affected persons and the complexity of their needs places just as much of a burden on the health care system as does the plethora of often poorly coordinated interventions. The Chronic Care Model developed for different chronic diseases is suited for improving medical care. The PRISCUS research consortium was established to create the prerequisites for a new care model for multimorbid, elderly patients oriented along those lines.MethodsThe research consortium utilizes data gathered in a large-scale epidemiological study on peripheral arterial disease (getABI study) and from the Dortmund and Münster stroke registries, by extracting epidemiologic and health economic data, quality-of-life parameters, and data on the extent and quality of medication. Additional projects evaluate the implementation of a multidimensional geriatric assessment in primary care, the functional consequences of multimorbidity in stroke patients along with options for prevention and therapy afforded by physical activity. Systematic reviews of the literature are used to describe quality of life and patient preferences. Experts will work on an initial draft treatment standard for patients with multimorbidity and a list of potentially inappropriate medication for the elderly in Germany.ConclusionThe results of the PRISCUS research consortium will enable an epidemiologic characterization and description of consequences of multimorbidity, while illustrating new approaches towards prevention, diagnosis, and management of multimorbid patients. With this, some prerequisites for a new health care model for patients with multimorbidity comparable to the Chronic Care Model will be fulfilled.ZusammenfassungFragestellungDas gleichzeitige Auftreten oder Vorhandensein mehrerer chronischer Erkrankungen im Sinne einer Multimorbidität stellt den betroffenen Patienten, seine Angehörigen sowie Ärzte und Therapeuten vor große Herausforderungen. Das Gesundheitssystem wird durch die steigende Zahl Betroffener und ihre komplexen Bedürfnisse, aber auch durch die Vielfalt häufig schlecht koordinierter Interventionen zunehmend belastet. Zur Verbesserung der medizinischen Versorgung bietet sich das für chronisch Kranke entwickelte „Chronic Care Model“ an. Der Forschungsverbund PRISCUS versucht, die Voraussetzungen für ein daran orientiertes, neues Versorgungsmodell für multimorbide, ältere Patienten zu schaffen.MethodikDer Verbund nutzt unter anderem Daten einer großen epidemiologischen Studie zur peripheren arteriellen Verschlusskrankheit (getABI-Studie) und Daten des Dortmunder und Münsteraner Schlaganfallregisters. Ermittelt werden epidemiologische und gesundheitsökonomische Daten, Parameter der Lebensqualität und Umfang und Qualität der medikamentösen Versorgung. In weiteren Projekten werden die Implementierung eines multidimensionalen Assessments in Hausarztpraxen, die funktionellen Auswirkungen von Multimorbidität bei Schlaganfallpatienten sowie Möglichkeiten der Prävention und Therapie mittels körperlicher Aktivität evaluiert. Über systematische Literaturübersichten werden Lebensqualität und Patientenpräferenzen dargestellt. Mit Hilfe von Experten wird ein erster Behandlungsstandard für Patienten mit Multimorbidität und eine Liste potentiell inadäquater Medikamente im Alter erarbeitet.FazitDie Ergebnisse des Forschungsverbunds werden eine epidemiologische Charakterisierung und eine Abschätzung der Krankheitsfolgen von Multimorbidität erlauben. Der Verbund wird neue Ansätze zu Prävention, Diagnostik und Therapie bei Multimorbidität aufzeigen können. Damit werden erste Voraussetzungen geschaffen, durch Anpassung der Versorgungsstruktur nach Vorbild des „Chronic Care Model“ ein verbessertes Management von Patienten mit Multimorbidität zu erreichen.

General practitioner advice on physical activity: Analyses in a cohort of older primary health care patients (getABI)

BackgroundAlthough the benefits of physical activity for health and functioning are recognized to extend throughout life, the physical activity level of most older people is insufficient with respect to current guidelines. The primary health care setting may offer an opportunity to influence and to support older people to become physically active on a regular basis. Currently, there is a lack of data concerning general practitioner (GP) advice on physical activity in Germany. Therefore, the aim of this study was to evaluate the rate and characteristics of older patients receiving advice on physical activity from their GP.MethodsThis is a cross-sectional study using data collected at 7 years of follow-up of a prospective cohort study (German epidemiological trial on ankle brachial index, getABI). 6,880 unselected patients aged 65 years and above in the primary health care setting in Germany were followed up since October 2001. During the 7-year follow-up telephone interview, 1,937 patients were asked whether their GP had advised them to get regular physical activity within the preceding 12 months. The interview also included questions on socio-demographic and lifestyle variables, medical conditions, and physical activity. Logistic regression analysis (unadjusted and adjusted for all covariables) was used to examine factors associated with receiving advice. Analyses comprised only complete cases with regard to the analysed variables. Results are expressed as odds ratios (ORs) with 95% confidence intervals (95% CI).ResultsOf the 1,627 analysed patients (median age 77; range 72-93 years; 52.5% women), 534 (32.8%) stated that they had been advised to get regular physical activity. In the adjusted model, those more likely to receive GP advice on physical activity were men (OR [95% CI] 1.34 [1.06-1.70]), patients suffering from pain (1.43 [1.13-1.81]), coronary heart disease and/or myocardial infarction (1.56 [1.21-2.01]), diabetes mellitus (1.79 [1.39-2.30]) or arthritis (1.37 [1.08-1.73]), and patients taking a high (> 5) number of medications (1.41 [1.11-1.80]).ConclusionsThe study revealed a relatively low rate of older primary health care patients receiving GP advice on physical activity. GPs appeared to focus their advice on patients with chronic medical conditions. However, there are likely to be many more patients who would benefit from advice.

Prevalence of Self-Reported Pain, Joint Complaints and Knee or Hip Complaints in Adults Aged ≥ 40 Years: A Cross-Sectional Survey in Herne, Germany

Background Pain and musculoskeletal complaints are among the most common symptoms in the general population. Despite their epidemiological, clinical and health economic importance, prevalence data on pain and musculoskeletal complaints for Germany are scarce. Methods A cross-sectional survey of a random sample of citizens of Herne, Germany, aged ≥ 40 years was performed. A detailed self-complete postal questionnaire was used, followed by a short reminder questionnaire and telephone contacts for those not responding. The questionnaire contained 66 items, mainly addressing pain of any site, musculoskeletal complaints of any site and of knee and hip, pain intensities, the Western Ontario MacMaster Universities (WOMAC) index, medication, health care utilization, comorbidities, and quality of life. Results The response rate was 57.8% (4,527 of 7,828 individuals). Survey participants were on average 1.3 years older, and the proportion of women among responders tended to be greater than in the population sample. There was no age difference between the population sample and 2,221 participants filling out the detailed questionnaire. The following standardized prevalences were assessed: current pain: 59.7%, pain within the past four weeks: 74.5%, current joint complaints: 49.3%, joint complaints within the past four weeks and twelve month: 62.8% and 67.4%, respectively, knee as the site predominantly affected: 30.9%, knee bilateral: 9.7%, hip: 15.2%, hip bilateral: 3.5%, knee and hip: 5.5%. Pain and musculoskeletal complaints were significantly more often reported by women. A typical relationship of pain and joint complaints to age could be found, i.e. increasing prevalences with increasing age categories, with a drop in the highest age groups. In general, pain and joint pain were associated with comorbidity and body mass index as well as quality of life. Conclusions Our data confirm findings of other recent national as well as European surveys. The high site specific prevalences of knee and hip complaints underline the necessity to further investigate characteristics and consequences of pain and symptomatic osteoarthritis of these joints in adults in Germany.

Prerequisites for a new health care model for elderly people with multimorbidity

Fragestellung Das gleichzeitige Auftreten oder Vorhandensein mehrerer chronischer Erkrankungen im Sinne einer Multimorbiditat stellt den betroffenen Patienten, seine Angehorigen sowie Arzte und Therapeuten vor grose Herausforderungen. Das Gesundheitssystem wird durch die steigende Zahl Betroffener und ihre komplexen Bedurfnisse, aber auch durch die Vielfalt haufig schlecht koordinierter Interventionen zunehmend belastet. Zur Verbesserung der medizinischen Versorgung bietet sich das fur chronisch Kranke entwickelte „Chronic Care Model“ an. Der Forschungsverbund PRISCUS versucht, die Voraussetzungen fur ein daran orientiertes, neues Versorgungsmodell fur multimorbide, altere Patienten zu schaffen.BackgroundMultimorbidity, the concurrent manifestation or presence of multiple chronic conditions, poses huge challenges to affected patients, their relatives, physicians, and practitioners alike. The growing number of affected persons and the complexity of their needs places just as much of a burden on the health care system as does the plethora of often poorly coordinated interventions. The Chronic Care Model developed for different chronic diseases is suited for improving medical care. The PRISCUS research consortium was established to create the prerequisites for a new care model for multimorbid, elderly patients oriented along those lines.MethodsThe research consortium utilizes data gathered in a large-scale epidemiological study on peripheral arterial disease (getABI study) and from the Dortmund and Münster stroke registries, by extracting epidemiologic and health economic data, quality-of-life parameters, and data on the extent and quality of medication. Additional projects evaluate the implementation of a multidimensional geriatric assessment in primary care, the functional consequences of multimorbidity in stroke patients along with options for prevention and therapy afforded by physical activity. Systematic reviews of the literature are used to describe quality of life and patient preferences. Experts will work on an initial draft treatment standard for patients with multimorbidity and a list of potentially inappropriate medication for the elderly in Germany.ConclusionThe results of the PRISCUS research consortium will enable an epidemiologic characterization and description of consequences of multimorbidity, while illustrating new approaches towards prevention, diagnosis, and management of multimorbid patients. With this, some prerequisites for a new health care model for patients with multimorbidity comparable to the Chronic Care Model will be fulfilled.ZusammenfassungFragestellungDas gleichzeitige Auftreten oder Vorhandensein mehrerer chronischer Erkrankungen im Sinne einer Multimorbidität stellt den betroffenen Patienten, seine Angehörigen sowie Ärzte und Therapeuten vor große Herausforderungen. Das Gesundheitssystem wird durch die steigende Zahl Betroffener und ihre komplexen Bedürfnisse, aber auch durch die Vielfalt häufig schlecht koordinierter Interventionen zunehmend belastet. Zur Verbesserung der medizinischen Versorgung bietet sich das für chronisch Kranke entwickelte „Chronic Care Model“ an. Der Forschungsverbund PRISCUS versucht, die Voraussetzungen für ein daran orientiertes, neues Versorgungsmodell für multimorbide, ältere Patienten zu schaffen.MethodikDer Verbund nutzt unter anderem Daten einer großen epidemiologischen Studie zur peripheren arteriellen Verschlusskrankheit (getABI-Studie) und Daten des Dortmunder und Münsteraner Schlaganfallregisters. Ermittelt werden epidemiologische und gesundheitsökonomische Daten, Parameter der Lebensqualität und Umfang und Qualität der medikamentösen Versorgung. In weiteren Projekten werden die Implementierung eines multidimensionalen Assessments in Hausarztpraxen, die funktionellen Auswirkungen von Multimorbidität bei Schlaganfallpatienten sowie Möglichkeiten der Prävention und Therapie mittels körperlicher Aktivität evaluiert. Über systematische Literaturübersichten werden Lebensqualität und Patientenpräferenzen dargestellt. Mit Hilfe von Experten wird ein erster Behandlungsstandard für Patienten mit Multimorbidität und eine Liste potentiell inadäquater Medikamente im Alter erarbeitet.FazitDie Ergebnisse des Forschungsverbunds werden eine epidemiologische Charakterisierung und eine Abschätzung der Krankheitsfolgen von Multimorbidität erlauben. Der Verbund wird neue Ansätze zu Prävention, Diagnostik und Therapie bei Multimorbidität aufzeigen können. Damit werden erste Voraussetzungen geschaffen, durch Anpassung der Versorgungsstruktur nach Vorbild des „Chronic Care Model“ ein verbessertes Management von Patienten mit Multimorbidität zu erreichen.