Additional Chronic Condition Research Articles

Excess of health care use in general practice and of comorbid chronic conditions in cancer patients compared to controls

BackgroundThe number of cancer patients and the number of patients surviving initial treatments is expected to rise. Traditionally, follow-up monitoring takes place in secondary care. The contribution of general practice is less visible and not clearly defined.This study aimed to compare healthcare use in general practice of patients with cancer during the follow-up phase compared with patients without cancer. We also examined the influence of comorbid conditions on healthcare utilisation by these patients in general practice.MethodsWe compared health care use of N=8,703 cancer patients with an age and gender-matched control group of patients without cancer from the same practice. Data originate from the Netherlands Information Network of General Practice (LINH), a representative network consisting of 92 general practices with 350,000 enlisted patients. Health care utilisation was assessed using data on contacts with general practice, prescription and referral rates recorded between 1/1/2001 and 31/12/2007. The existence of additional comorbid chronic conditions (ICPC coded) was taken into account.ResultsCompared to matched controls, cancer patients had more contacts with their GP-practice (19.5 vs. 11.9, p<.01), more consultations with the GP (3.5 vs. 2.7, p<.01), more home visits (1.6 vs. 0.4, p<.01) and they got more medicines prescribed (18.7 vs. 11.6, p<.01) during the follow-up phase. Cancer patients more often had a chronic condition than their matched controls (52% vs. 44%, p<.01). Having a chronic condition increased health care use for both patients with and without cancer. Cancer patients with a comorbid condition had the highest health care use.ConclusionWe found that cancer patients in the follow-up phase consulted general practice more often and suffered more often from comorbid chronic conditions, compared to patients without cancer. It is expected that the number of cancer patients will rise in the years to come and that primary health care professionals will be more involved in follow-up care. Care for comorbid chronic conditions, communication between specialists and GPs, and coordination of tasks then need special attention.

Supporting health behaviour change in chronic obstructive pulmonary disease with telephone health-mentoring: insights from a qualitative study

BackgroundAdoption and maintenance of healthy behaviours is pivotal to chronic disease self-management as this influences disease progression and impact. This qualitative study investigated health behaviour changes adopted by participants with moderate or severe chronic obstructive pulmonary disease (COPD) recruited to a randomised controlled study of telephone-delivered health-mentoring.MethodsCommunity nurses trained as health-mentors used a patient-centred approach with COPD patients recruited in general practice to facilitate behaviour change, using a framework of health behaviours; ‘SNAPPS’ Smoking, Nutrition, Alcohol, Physical activity, Psychosocial well-being, and Symptom management, through regular phone calls over 12 months. Semi-structured interviews in a purposive sample sought feedback on mentoring and behaviour changes adopted. Interviews were analysed using iterative thematic and interpretative content approaches by two investigators.ResultsOf 90 participants allocated to health-mentoring, 65 (72%) were invited for interview at 12-month follow up. The 44 interviewees, 75% with moderate COPD, had a median of 13 mentor contacts over 12 months, range 5–20. Interviewed participants (n = 44, 55% male, 43% current smokers, 75% moderate COPD) were representative of the total group with a mean age 65 years while 82% had at least one additional co-morbid chronic condition. Telephone delivery was highly acceptable and enabled good rapport. Participants rated ‘being listened to by a caring health professional’ as very valuable. Three participant groups were identified by attitude to health behaviour change: 14 (32%) actively making changes; 18 (41%) open to and making some changes and 12 (27%) more resistant to change. COPD severity or current smoking status was not related to group category. Mentoring increased awareness of COPD effects, helping develop and personalise behaviour change strategies, even by those not actively making changes. Physical activity was targeted by 43 (98%) participants and smoking by 14 (74%) current smokers with 21% reporting quitting. Motivation to maintain changes was increased by mentor support.ConclusionsTelephone delivery of health-mentoring is feasible and acceptable to people with COPD in primary care. Health behaviours targeted by this population, mostly with moderate disease, were mainly physical activity and smoking reduction or cessation. Health-mentoring increased motivation and assisted people to develop strategies for making and sustaining beneficial change.Trial registrationACTR12608000112368

Auswirkungen von Multimorbidität auf die Inanspruchnahme medizinischer Versorgungsleistungen und die Versorgungskosten

Multiple chronic conditions (multimorbidity) are common among elderly patients; however, little is known about the specific effects of multimorbidity on health care utilization and health care costs. This article reviews empirical studies from the international literature that investigated the relationship between multiple chronic conditions and health care utilization (e.g. ambulatory care, stationary care, pharmacotherapy) and/or health care costs in elderly general populations. Although synthesis of studies was complicated, especially because of ambiguous definitions and measurements of multimorbidity, almost all studies observed a positive association of multimorbidity and utilization and costs. Many studies found that utilization and costs significantly increased with each additional chronic condition. In light of these findings coupled with the fear that current care arrangements may be inappropriate for many multimorbid patients, important implications for research and policy are presented and discussed.

Toward a More Cogent Approach to the Challenges of Multimorbidity

This issue of the Annals, as well as the previous one, confronts the enormous public health challenges of multimorbidity. More than 1 in 4 Americans has multiple (2 or more) chronic conditions, including physical and behavioral health problems, accounting for an estimated two-thirds of total US health care spending.1 An individual’s risks for a variety of adverse health outcomes (eg, poor functional status, unnecessary hospitalizations, and adverse drug events) rise as the number of multiple chronic conditions increases.2 The Centers for Medicare and Medicaid Services (CMS) has just released even more detailed information with respect to its Medicare fee-for-service populations,3 exposing the exceptional complexity and sheer burden that multiple chronic conditions pose for patients, health facilities, payers, and clinicians. In its recently released chart book Chronic Conditions Among Medicare Beneficiaries,3 CMS describes detailed demographics and prevalence measures of multiple medical conditions in this population and the dramatic impact on service utilization and spending. Examples of key findings are that two-thirds (20.7 million beneficiaries) had at least 2 or more chronic conditions; about 50% of beneficiaries with stroke or heart failure had 5 or more additional chronic conditions; beneficiaries with 6 or more chronic conditions accounted for about one-half of Medicare spending on hospitalizations; more than one-quarter of beneficiaries with 6 or more chronic conditions had a hospital readmission within 30 days; and the 12% of beneficiaries with 6 or more chronic conditions accounted for 43% of Medicare spending. For health systems that have traditionally focused on research and treatment of single conditions, these tremendous challenges have forced many to escalate efforts to identify and implement solutions. How do we as a society bring a greater sense of order to this vexing challenge? As part of the response, the US Department of Health and Human Services (HHS), in conjunction with partner organizations and other stakeholders, used a deliberative process to develop Multiple Chronic Conditions—A Strategic Framework: Optimum Health and Quality of Life for Individuals with Multiple Chronic Conditions.2 The framework serves as a national-level road map to assist HHS programs and public and private stakeholders in ensuring a more coordinated and comprehensive approach to improving the health status of individuals with multiple chronic conditions.2,4 Released to stakeholders and the public in late 2010, the framework is organized into 4 major goal areas with subsets of objectives and action strategies for use by clinical practitioners, policy makers, researchers, and others. The framework’s goals encompass the interdependent domains of (1) strengthening the health care and public health systems; (2) empowering the individual to use self-care management; (3) equipping health care clinicians with tools, information, and other interventions; and (4) supporting targeted research about individuals with multiple chronic conditions and effective interventions. The 3 articles on multimorbidity included in this issue of the Annals,5–7 which focus on measurement, represent progress in better understanding the epidemiology of multiple chronic conditions, a key aspect of the HHS strategic framework’s fourth goal. The articles further illustrate that there are multiple operational definitions of multimorbidity, each with their respective strengths and weaknesses. Though each may be appropriate according to the outcome of interest, there also may be utility for some degree of standardization in characterizing this heterogeneous population. The definition for multiple chronic conditions used in the HHS strategic framework utilized an approach of simple counts of conditions (ie, 2 or more). The article by Huntley et al, consistent with this approach, finds that simple counts of diseases perform almost as well as complex measures in predicting most outcomes.5 Ultimately, however, from a policy perspective, what generally holds true irrespective of the selected measure is that as the magnitude of multimorbidity increases, patient outcomes decline and costs rise. Thus, targeting care management efforts on multimorbid populations should, in principle, accelerate the country’s progress toward the goals of delivery system reform. We invite readers to further their familiarity with the complex issues posed by multiple chronic conditions by reviewing the HHS strategic framework and related activities (http://www.hhs.gov/ash/initiatives/mcc).8 A current HHS collaborative initiative—led by CMS, the Centers for Disease Control and Prevention, and the Agency for Healthcare Research & Quality—is not only examining options for a conceptual framework to improve definition and measurement of priority chronic conditions, but also is conducting coordinated analyses of multiple data sets to improve descriptive epidemiological characterization of multiple chronic conditions. Increasing life expectancy and the aging of the population will only intensify the challenge for the future. The articles in this issue begin to address an enormous health system challenge that demands our urgent attention.

Medically Complex Children: An Increasing Inpatient Population

Dr Olasin has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device Source: Burns KH, Casey PH, Lyle RE, et al. Increasing prevalence of medically complex children in US hospitals. Pediatrics. 2010; 126( 4): 638– 645; doi: 1031542/peds.2009-1658[OpenUrl][1][Abstract/FREE Full Text][2] Investigators from Arkansas used national data to evaluate changes in hospitalization rates for children aged 8 days to 4 years with complex chronic conditions (CCC) from 1991 through 2005. Medically complex children were defined as individuals in a designated chronic condition category involving more than one organ system, such as children with a specific condition (eg, cerebral palsy [CP] or bronchopulmonary dysplasia [BPD]) and an additional chronic condition. The CCC included multisystem specific comorbidities: neuromuscular, … [1]: {openurl}?query=rft.jtitle%253DPediatrics%26rft_id%253Dinfo%253Adoi%252F10.1542%252Fpeds.2009-1658%26rft_id%253Dinfo%253Apmid%252F20855383%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/ijlink?linkType=ABST&journalCode=pediatrics&resid=126/4/638&atom=%2Faapgrand%2F25%2F2%2F24.atom

Risk factors for hospital-acquired ‘poor glycemic control’: a case–control study

To determine the patient and hospital characteristics associated with severe manifestations of 'poor glycemic control'-a 'no-pay' hospital-acquired condition defined by the US Medicare program based on hospital claims related to severe complications of diabetes. A nested case-control study. California acute care hospitals from 2005 to 2006. All cases (n= 261) with manifestations of poor glycemic control not present on admission admitted to California acute care hospitals from 2005 to 2006 and 261 controls were matched (1:1) using administrative data for age, sex, major diagnostic category and severity of illness. The adjusted odds ratio (OR) for experiencing poor glycemic control. Deaths (16 vs. 9%, P= 0.01) and total costs ($26,125 vs. $18,233, P= 0.026) were significantly higher among poor glycemic control cases. Risk-adjusted conditional logistic regression revealed that each additional chronic condition increased the odds of poor glycemic control by 12% (OR: 1.12, 95% CI: 1.04-1.22). The interaction of registered nurse staffing and hospital teaching status suggested that in non-teaching hospitals, each additional nursing hour per adjusted patient day significantly reduced the odds of poor glycemic control by 16% (OR: 0.84, 95% CI: 0.73-0.96). Nurse staffing was not significant in teaching hospitals (OR: 0.98, 95% CI: 0.88-1.11). Severe poor glycemic control complications are relatively rare but meaningful events with disproportionately high costs and mortality. Increasing nurse staffing may be an effective strategy in reducing poor glycemic control complications particularly in non-teaching hospitals.

Factors associated with self-rated health in older people living in institutions

BackgroundAlthough self-rated health has been extensively studied in community older people, its determinants have seldom been investigated in institutional settings. We carried out a cross-sectional study to describe the physical, mental, and social factors associated with self-rated health in nursing homes and other geriatric facilities.MethodsA representative sample of 800 subjects 65 years of age and older living in 19 public and 30 private institutions of Madrid was randomly selected through stratified cluster sampling. Residents, caregivers, physicians, and nurses were interviewed by trained geriatricians using standardized instruments to assess self-rated health, chronic illnesses, functional capacity, cognitive status, depressive symptoms, vision and hearing problems, and social support.ResultsOf the 669 interviewed residents (response rate 84%), 55% rated their health as good or very good. There was no association with sex or age. Residents in private facilities and those who completed primary education had significantly better health perception. The adjusted odds ratio (95% confidence interval) for worse health perception was 1.18 (1.07–1.28) for each additional chronic condition, 2.37 (1.38–4.06) when comparing residents with moderate dependency to those functionally independent, and 10.45 (5.84–18.68) when comparing residents with moderate/severe depressive symptoms to those without symptoms. Visual problems were also associated with worse health perception. Similar results were obtained in subgroup analyses, except for inconsistencies in cognitively impaired individuals.ConclusionChronic conditions, functional status, depressive symptoms and socioeconomic factors were the main determinants of perceived health among Spanish institutionalized elderly persons. Doubts remain about the proper assessment of subjective health in residents with altered cognition.

Physical Activity and Health in Canadian Asthmatics

Asthma is a chronic respiratory disease affecting approximately 8% of the Canadian population. Being physically active may assist in management of the disease and lead to improvements in overall health. The purpose of this study was to determine whether involvement in physical activity (PA) influenced self-reported measures of health in asthmatics. The sample included 4272 asthmatic men and 6971 asthmatic women who participated in the Canadian Community Health Survey cycle 2.1. The median age for this group fell in the 40–44 age category. PA level was classified into three categories: active, moderately active, or inactive. In order to determine the relationship between PA levels and the five measures of health (self-perceived health, self-perceived mental health, additional chronic conditions, functional limitations, and satisfaction with life in general) Kruskal-Wallis ANOVAs were conducted and pairwise comparisons were used when significant main effects occurred. For all five measures of health, being physically active increased the likelihood of better health, and greater levels of PA were associated with higher values. In summary, PA was consistently associated with better health in Canadians with asthma. Future research is required to confirm a linear dose-response relationship between PA and health in asthmatics.

Neurological and Neuromuscular Disease as a Risk Factor for Respiratory Failure in Children Hospitalized With Influenza Infection

The Advisory Committee on Immunization Practices (ACIP) recommends annual influenza vaccination for children with certain chronic medical conditions to prevent serious complications of influenza infection. Little is known about the relative contribution of each of these chronic medical conditions to the development of serious influenza-associated complications. To identify chronic medical conditions that are associated with respiratory failure in children hospitalized with community-acquired laboratory-confirmed influenza. A retrospective cohort study of patients aged 21 years or younger hospitalized at The Children's Hospital of Philadelphia with community-acquired laboratory-confirmed influenza during 4 consecutive influenza seasons (June 2000 through May 2004). We examined 9 ACIP-designated high-risk chronic medical conditions and 3 additional chronic medical conditions (neurological and neuromuscular disease [NNMD], gastroesophageal reflux disease [GERD], and history of prematurity) that in recent studies have been associated with influenza hospitalization and severe influenza-related complications. Rate and odds ratio (OR) of respiratory failure, defined as need for mechanical ventilation. Of 745 children hospitalized with community-acquired laboratory-confirmed influenza, 322 (43%) had 1 or more ACIP-designated high-risk chronic medical conditions. Neurological and neuromuscular disease, GERD, and history of prematurity were present in 12%, 14%, and 3%, of children, respectively. Thirty-two children (4.3%) developed respiratory failure. In multivariate logistic regression analyses, conditions associated with respiratory failure included NNMD (OR, 6.0; 95% confidence interval [CI], 2.7-13.5), chronic pulmonary disease other than asthma (OR, 4.8; 95% CI, 1.5-15.1), and cardiac disease (OR, 4.0; 95% CI, 1.6-10.2). The predicted probabilities of respiratory failure derived from the multivariate model were 12% (95% CI, 7%-20%), 9% (95% CI, 3%-23%), and 8% (95% CI, 4%-18%) for children with NNMD, chronic pulmonary disease, and cardiac disease, respectively. These results support the ACIP's recent decision to add NNMD to the list of conditions for which annual influenza vaccine is recommended in children. Neurologists and primary care pediatricians should be alerted to the increased risk of respiratory failure and the importance of influenza vaccination in children with NNMD.

Gene Therapy for the Treatment of Musculoskeletal Diseases

Research into the orthopaedic applications of gene therapy has resulted in progress toward managing chronic and acute genetic and nongenetic disorders. Gene therapy for arthritis, the original focus of research, has progressed to the initiation of several phase I clinical trials. Preliminary findings support the application of gene therapy in the treatment of additional chronic conditions, including osteoporosis and aseptic loosening, as well as musculoskeletal tumors. The most rapid progress is likely to be in tissue repair because it requires neither long-term transgene expression nor closely regulated levels of transgene expression. Moreover, healing probably can be achieved with existing technology. In preclinical studies, genetically modulated stimulation of bone healing has shown impressive results in repairing segmental defects in the long bones and cranium and in improving the success of spinal fusions. An increasing amount of evidence indicates that gene transfer can aid the repair of articular cartilage, menisci, intervertebral disks, ligaments, and tendons. These developments have the potential to transform many areas of musculoskeletal care, leading to treatments that are less invasive, more effective, and less expensive than existing modalities.

Symptom exacerbation and hospitalization for heart failure: onset time, progression, and severity

Congestive heart failure (CHF) is generally described as a clinical syndrome characterized by impairments to the structure and function of the heart. CHF symptom exacerbation is responsible for more than 1 million hospital admissions annually and represents one of the largest Medicare expenditures. The purpose of this study was to determine the onset, progression, and severity of acute symptoms experienced prior to hospital admission. The specific aims of the study were to (i) describe onset times for acute symptoms, (ii) assess the severity of these symptoms prior to admission, and (iii) identify predictors of increased onset and severity of acute symptoms among persons with CHF. A total of 127 patients were interviewed following emergency admission to an urban university medical center. Interviews evaluated acute symptom scores, recent time-activity patterns, and chronic CHF experience. Acute symptoms (including shortness of breath, fatigue, and swelling) were assessed with a 10-point visual analog scale at four time periods prior to and at admission. In addition, follow-up information was collected by phone interview at 4 to 6 weeks after discharge. Average symptom scores demonstrated progressive worsening prior to admission. Two weeks before admission, the mean score for shortness of breath was 4.6 (SD = 3.0). At admission, this increased to 7.5 (SD = 2.9). Scores for other symptoms showed similar gains. Participants with self-described mild CHF reported greater increases in symptom scores at hospital admission compared with those with moderate or severe illness. Ranked scores did not differ for patients with prolonged discomfort compared with those describing rapid onset of symptom exacerbation. Patients hospitalized for exacerbation of CHF experience progressive worsening of acute symptoms prior to admission. The presence of additional chronic conditions, more severe CHF, and comorbid illnesses predict higher acute symptom scores. The understanding of the temporal onset of acute symptoms can aid in education and awareness for patients at risk of hospital admission due to aggravated heart failure conditions.

Cigarette Smoking-Attributable Morbidity

Cigarette Smoking-Attributable Morbidity

Not on Their Own Again: Psychological, Social, and Health Characteristics of Custodial African American Grandmothers

SUMMARY The article presents social and health indicators of depression among custodial African American grandmothers. Using a cross-sectional design, a sample of 99 custodial African American grandmothers caring for one or more grandchildren was included in the analysis. The results indicated that approximately 20% of custodial African American grandmothers were depressed. Depressed grandmothers were more likely to report having all ten chronic physical health conditions listed in the study. One additional chronic condition increased the probability of depression by 68%. Old age, more social support, and caring for older children were associated with low levels of depression. The proliferation of grandchildren being raised by African American grandmothers suggests the need for more research, policy, and programmatic interventions.