Co-occurrence Of Chronic Conditions Research Articles

204-LB: Lifestyle Risk Behaviors among Stroke Survivors With and Without Diabetes

Objective: History of stroke or diabetes increases risk for cardiometabolic conditions, which can be exacerbated by the presence of modifiable lifestyle risk behaviors. The purpose of this study was to evaluate lifestyle risk behaviors among stroke survivors with and without diabetes to inform future research and healthcare intervention. Specifically, we compared the prevalence of three lifestyle risk behaviors (i.e., consuming ≤1 fruit and ≤1 vegetable daily, physical inactivity, and overweight/obesity) and total number of lifestyle risk behaviors among stroke survivors, stratified by diabetes status. Methods: Cross-sectional data from the 2013 and 2015 Behavioral Risk Factor Surveillance System (BRFSS) were examined. Weighted and age-adjusted prevalence estimates and adjusted odds ratios (AOR, adjusted for sociodemographic characteristics) with 95% confidence intervals (CIs) were calculated to compare prevalence and odds of individual and total number of lifestyle risk behaviors between stroke survivors with and without diabetes. Results: Prevalence and AORs were higher in stroke survivors with diabetes compared to stroke survivors without diabetes for consuming ≤1 fruit and ≤1 vegetable daily (58.8% vs. 53.7%; AOR: 1.14, CI: 1.02-1.28), physical inactivity (65.7% vs. 54.6%; AOR: 1.41, CI: 1.26-1.58), overweight/obesity (87.2% vs. 63.1%; AOR: 2.42, CI: 2.12-2.79), 2 lifestyle risk behaviors (41.1% vs. 36.7%; AOR: 1.16, CI: 1.03-1.30), and 3 lifestyle risk behaviors (35.7% vs. 21.8%; AOR: 1.54, CI: 1.36-1.74). Conclusion: Individual and clustered lifestyle risk behaviors were present in greater proportions among stroke survivors with diabetes compared to those without diabetes. Because the co-occurrence of chronic conditions (i.e., multimorbidity) and multiple lifestyle risk behaviors increases risk for poor health and premature death, effective healthcare interventions and community programs are needed to promote health behavior change in stroke survivors. Disclosure R.R. Bailey: None. A. Phad: None. R. McGrath: None. A. Ford: None. R.G. Tabak: Other Relationship; Self; Envolve PeopleCare/Centene Corporation. N.H. Serrano: None. D. Haire-Joshu: Research Support; Self; Centene Corporation. Funding National Institutes of Health (P30DK092950, 5T32HL130357)

Complex Multimorbidity and Breast Cancer Screening Among Midlife and Older Women: The Role of Perceived Need.

There is minimal survival benefit to cancer screening for those with poor clinical presentation (complex multimorbidity) or at advanced ages. The current screening mammography guidelines consider these objective indicators. There has been less attention, however, to women's subjective assessment of screening need. This study examines the interplay between complex multimorbidity, age, and subjective assessments of health and longevity for screening mammography receipt. This cross-sectional study uses self-reported data from 8,938 women over the age of 52 in the 2012 Health and Retirement Study. Logistic regression models estimated the association between women's complex multimorbidity (co-occurrence of chronic conditions, functional limitations, and/or geriatric syndromes), subjective health and longevity assessments, age, and screening mammography in the 2 years before the interview. These associations were evaluated adjusting for sociodemographic and behavioral factors. Both age and complex multimorbidity were negatively associated with screening mammography. However, women's perceived need for screening moderated these effects. Most significantly, women optimistic about their chances of living another 10-15 years were more likely to have had screening mammography regardless of their health conditions or advanced age. Women with more favorable self-assessed health and perceived life expectancy were more likely to receive screening mammography even if they have poor clinical presentation or advanced age. This is contrary to current cancer screening guidelines and suggests an opportunity to engage women's subjective health and longevity assessments for cancer screening decision making in both for screening policy and in individual clinician recommendations.

Integrated Care for High-need High-cost Patients: The Comprehensive Care for Multimorbid Adults Program (CC-MAP)

Introduction : Multimorbidity, the co-occurrence of chronic conditions, is common and associated with substantial burden to patients and healthcare systems. Yet, evidence on the effectiveness of multimorbid primary care programs is limited. We aimed to describe the Comprehensive Care for Multimorbid Adults Program (CC-MAP) and report 12-month hospitalization, quality of life and quality of care outcomes. Methods : A cluster-controlled design of primary care clinics in Clalit Health Services, Israel's largest non-for-profit insurer and provider of services. A total of 1200 (600 in each arm) high-risk multimorbid patients were recruited for a study of primary care clinics participating in the intervention and in comparable, usual care, controls. Clinics with a high proportion of patients with high morbidity burden, measured by the Johns Hopkins Adjusted Clinical Groups (JH-ACG)® weighted score, where chosen for the intervention and similar clinics were chosen as controls . In each of the intervention clinics, a nurse collaborated with 3-4 primary care physicians (PCP) to care for the 100 highest-risk multimorbid patients. Nurses performed comprehensive assessment; designed an all-inclusive care plan; developed a patient tailored action-plan, provide integration of all services and care transitions, and provided self-management support, and care integration. The PCP collaborated with the CC-MAP nurse, mainly in regards to receiving information from the comprehensive assessment she performed and in the joint creation of the care plan and its follow-up. Unplanned hospitalizations, self-reported physical component score (PCS) and mental component score (MCS) of the SF-12v2, and quality of care (using the Patient Assessment of Chronic Illness Care, [PACIC]), were assessed 12 months after recruitment. Results : Patients in the control group were not significantly different from patients in the intervention in regards to clinical characteristics and prior hospitalizations. PCS and PACIC scores were significantly higher in the intervention versus controls (p Discussions : The CC-MAP provides an effective comprehensive approach to reduce unwarranted healthcare utilization and maintain physical status of multimorbid patients. Conclusions : The CC-MAP provides an effective approach to patient selection and care provision for multimorbid patients, resulting in improved care, physical quality of life and reduced unplanned admissions. The program was recently expanded and currently includes 12 clinics in 3 districts. Lessons Learned : This study demonstrates the key features of successful multimorbidity primary care management programs and principles of equitable high-risk multimorbid case selection. The mental health components of the intervention should be strengthened. Limitations : The health care setting in which the study was performed (a large, integrated type of health care delivery system) may not resemble other health care systems. Nonetheless, similar principles of comprehensive multimorbid care management may be generalized. Suggestions for future research : Future research should examine long-term patients’ outcomes, as well as the involvement of patient’s caregivers’ in this process.

Abstract P6-02-01: Perceived life expectancy, multimorbidity, and breast cancer screening in older women

Abstract Objective: Screening mammography (SM) benefits are maximal in women who have a several years' life expectancy. Perceived life expectancy (PLE), however, can be compromised by older age, and/or poor health. Prior studies have shown low rates of SM in younger and/or healthier women, while women who are older and/or those presenting with multimorbidity (MM) continue to undergo screening. The resulting under/overuse of SM causes an imbalance in the use of finite resources that should be rectified as we prepare for population aging. In this study, we investigate the use of SM in women 50 years of age or older in the context of age, PLE, MM, and other social determinants of health. Methods: This is a cross-sectional study using the nationally-representative 2012 U.S. Health and Retirement Study (n= 8934 women). In addition to demographics, we examined a broad range of variables on social determinants of health; as well as conditions constituting MM, including self-reported chronic conditions (e.g., heart disease), functional limitations (e.g., strength, and mobility limitations), and geriatric syndromes (e.g., low cognitive performance). We defined MM0-MM3 as gradients of MM, based on the occurrence/co-occurrence of chronic conditions, functional limitations, and/or geriatric syndromes. PLE was calculated based on respondent's age-specific assessment of the chance they would live another 10-15 years. The outcome variable was self-reported mammography in the past 2 years. We conducted logistic regression analysis to evaluate the independent and interactive association between each of PLE and MM relative to SM, adjusting for potential confounders. Results: The median age was 65.7 years; 10.5% were Non-Hispanic Black (NHB), 7.8% were Hispanic, and 3.2% were Other Race. The percent of women with SM was 71.5% in the total population. The median assessment of PLE was a 50% chance of living another 10-15 years. 71.9% of women presented with chronic conditions, 36.8% with functional limitations, and 58.2 with geriatric syndromes. Adjusting for confounders, receipt of mammogram was positively associated with greater certainty of PLE (AOR for an increase of 10% –1.03 (1.01, 1.05)). Compared to those with no conditions (MM0), the co-occurrence of chronic conditions, functional limitations, and/or geriatric syndromes was also positively associated with SM (AOR MM1– 1.48 (1.19, 1.84); AOR MM2– 1.35 (1.09, 1.69); and AOR MM3– 1.29 (1.02, 1.62)). In addition, PLE further strengthened the association between MM and SM. Although age was negatively associated with SM, this interacted with PLE such that the likelihood of having a mammogram was unrelated to age among women 100% certain they would live another 10-15 years. Conclusion: Both multimorbidity (MM) and perceived life expectancy (PLE) are independently and interactively associated with increased screening mammography (SM), suggesting overuse. Indeed, even among women 75 years of age or older, when SM may be least beneficial, receipt of SM in the past two years was 59.6% in the presence of highest MM gradient, and 68.1% when they were at least 75% certain they will live 10-15 years. A more detailed examination of the basis for PLE is warranted to understand the context in which screening recommendation is made. Citation Format: Koroukian SM, Warner DF, Schiltz NK, Cooper GS, Owusu C, Stange KC, Berger NA. Perceived life expectancy, multimorbidity, and breast cancer screening in older women [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-02-01.

Changes in Case-Mix and Health Outcomes of Medicare Fee-for-Service Beneficiaries and Managed Care Enrollees During the Years 1992-2011.

Recent studies suggest that managed care enrollees (MCEs) and fee-for-service beneficiaries (FFSBs) have become similar in case-mix over time; but comparisons of health outcomes have yielded mixed results. To examine changes in differentials between MCEs and FFSBs both in case-mix and health outcomes over time. Temporal study of the linked Health and Retirement Study (HRS) and Medicare data, comparing case-mix and health outcomes between MCEs and FFSBs across 3 time periods: 1992-1998, 1999-2004, and 2005-2011. We used multivariable analysis, stratified by, and pooled across the study periods. The unit of analysis was the person-wave (n=167,204). HRS participants who were also enrolled in Medicare. Outcome measures included self-reported fair/poor health, 2-year self-rated worse health, and 2-year mortality. Our main covariate was a composite measure of multimorbidity (MM), MM0-MM3, defined as the co-occurrence of chronic conditions, functional limitations, and/or geriatric syndromes. The case-mix differential between MCEs and FFSBs persisted over time. Results from multivariable models on the pooled data and incorporating interaction terms between managed care status and study period indicated that MCEs and FFSBs were as likely to die within 2 years from the HRS interview (P=0.073). This likelihood remained unchanged across the study periods. However, MCEs were more likely than FFSBs to report fair/poor health in the third study period (change in probability for the interaction term: 0.024, P=0.008), but less likely to rate their health worse in the last 2 years, albeit at borderline significance (change in probability: -0.021, P=0.059). Despite the persistence of selection bias, the differential in self-reported fair/poor status between MCEs and FFSBs seems to be closing over time.

Increasing Burden of Complex Multimorbidity Across Gradients of Cognitive Impairment.

This study evaluates the burden of multimorbidity (MM) across gradients of cognitive impairment (CI). Using data from the 2010 Health and Retirement Study, we identified individuals with no CI, mild CI, and moderate/severe CI. In addition, we adopted an expansive definition of complex MM by accounting for the occurrence and co-occurrence of chronic conditions, functional limitations, and geriatric syndromes. In a sample of 18 913 participants (weighted n = 87.5 million), 1.93% and 1.84% presented with mild and moderate/severe CI, respectively. The prevalence of most conditions constituting complex MM increased markedly across the spectrum of CI. Further, the percentage of individuals presenting with 10 or more conditions was 19.9%, 39.3%, and 71.3% among those with no CI, mild CI, and moderate/severe CI, respectively. Greater CI is strongly associated with increased burden of complex MM. Detailed characterization of MM across CI gradients will help identify opportunities for health care improvement.

Complex multimorbidity and health outcomes in older adult cancer survivors.

To characterize complex multimorbidity among cancer survivors and evaluate the association between cancer survivorship, time since cancer diagnosis, and self-reported fair/poor health, self-rated worse health in 2 years, and 2-year mortality. We used the 2010-2012 Health and Retirement Study. Cancer survivors were individuals who reported a (nonskin) cancer diagnosis 2 years or more before the interview. We defined complex multimorbidity as the co-occurrence of chronic conditions, functional limitations, and/or geriatric syndromes. In addition to descriptive analyses, we used logistic regression to evaluate the independent association between cancer survivor status and health outcomes. We also examined whether cancer survivorship differed by the number of years since diagnosis. Among 15,808 older adults (age ≥50 years), 11.8% were cancer survivors. Compared with cancer-free individuals, a greater percentage of cancer survivors had complex multimorbidity: co-occurring chronic conditions, functional limitations, and geriatric syndromes. Cancer survivorship was significantly associated with self-reported fair/poor health, self-rated worse health in 2 years, and 2-year mortality. These effects declined with the number of years since diagnosis for fair/ poor health and mortality but not for self-rated worse health. Cancer survivor status is independently associated with more complex multimorbidity, and with worse health outcomes. These effects attenuate with time, except for patient perception of being in worse health.

Social determinants, multimorbidity, and patterns of end-of-life care in older adults dying from cancer.

Most prior studies on aggressive end-of-life care in older patients with cancer have accounted for social determinants of health (e.g., race, income, and education), but rarely for multimoribidity (MM). In this study, we examine the association between end-of-life care and each of the social determinants of health and MM, hypothesizing that higher MM is associated with less aggressive care. From the linked 1991-2008 Health and Retirement Study, Medicare data, and the National Death Index, we identified fee-for-service patients age ≥66years who died from cancer (n=835). MM was defined as the occurrence or co-occurrence of chronic conditions, functional limitations, and/or geriatric syndromes. Aggressive care was based on claims-derived measures of receipt of cancer-directed treatment in the last two weeks of life; admission to the hospital and/or emergency department (ED) within the last month; and in-hospital death. We also identified patients enrolled in hospice. In multivariable logistic regression models, we analyzed the associations of interest, adjusting for potential confounders. While 61.2% of the patients enrolled in hospice, 24.6% underwent cancer-directed treatment; 55.1% were admitted to the hospital and/or ED; and 21.7% died in the hospital. We observed a U-shaped distribution between income and in-hospital death. Chronic conditions and geriatric syndromes were associated with some outcomes, but not with others. To improve quality end-of-life care and curtail costs incurred by dying patients, relevant interventions need to account for social determinants of health and MM in a nuanced fashion.

Multimorbidity redefined: prospective health outcomes and the cumulative effect of co-occurring conditions.

IntroductionMultimorbidity is common among middle-aged and older adults; however the prospective effects of multimorbidity on health outcomes (health status, major health decline, and mortality) have not been fully explored. This study addresses this gap in the literature.MethodsWe used self-reported data from the 2008 and 2010 Health and Retirement Study. Our study population included 13,232 adults aged 50 or older. Our measure of baseline multimorbidity in 2008 was based on the occurrence or co-occurrence of chronic conditions, functional limitations, and/or geriatric syndromes, as follows: MM0, no chronic conditions, functional limitations, or geriatric syndromes; MM1, occurrence (but no co-occurrence) of chronic conditions, functional limitations, or geriatric syndromes; MM2, co-occurrence of any 2 of chronic conditions, functional limitations, or geriatric syndromes; and MM3, co-occurrence of all 3 of chronic conditions, functional limitations, and geriatric syndromes. Outcomes in 2010 included fair or poor health status, major health decline, and mortality.ResultsAll 3 outcomes were significantly associated with multimorbidity. Compared with MM0 (respectively for fair or poor health and major health decline), the adjusted odds ratios (AORs) and 95% confidence intervals were as follows: 2.61 (1.79–3.78) and 2.20 (1.42–3.41) for MM1; 7.49 (5.20–10.77) and 3.70 (2.40–5.71) for MM2; and 22.66 (15.64–32.83) and 4.72 (3.03–7.37) for MM3. Multimorbidity was also associated with mortality: an adult classified as MM3 was nearly 12 times (AOR, 11.87 [5.72–24.62]) as likely as an adult classified as MM0 to die within 2 years.ConclusionGiven the strong and significant association between multimorbidity and prospective health status, major health decline, and mortality, multimorbidity may be used — both in clinical practice and in research — to identify older adults with heightened vulnerability for adverse outcomes.

The increasing burden and complexity of multimorbidity.

BackgroundMultimorbidity, the co-occurrence of two or more chronic conditions, is common among older adults and is known to be associated with high costs and gaps in quality of care. Population-based estimates of multimorbidity are not readily available, which makes future planning a challenge. We aimed to estimate the population-based prevalence and trends of multimorbidity in Ontario, Canada and to examine patterns in the co-occurrence of chronic conditions.MethodsThis retrospective cohort study includes all Ontarians (aged 0 to 105 years) with at least one of 16 common chronic conditions. Descriptive statistics were used to examine and compare the prevalence of multimorbidity by age and number of conditions in 2003 and 2009. The co-occurrence of chronic conditions among individuals with multimorbidity was also explored.ResultsThe prevalence of multimorbidity among Ontarians rose from 17.4% in 2003 to 24.3% in 2009, a 40% increase. This increase over time was evident across all age groups. Within individual chronic conditions, multimorbidity rates ranged from 44% to 99%. Remarkably, there were no dominant patterns of co-occurring conditions.ConclusionThe high prevalence of multimorbidity and numerous combinations of conditions suggests that single, disease-oriented management programs may be less effective or efficient tools for high quality care compared to person-centered approaches.Electronic supplementary materialThe online version of this article (doi:10.1186/s12889-015-1733-2) contains supplementary material, which is available to authorized users.

Patterns of Multimorbidity in Primary Care Patients at High Risk of Future Hospitalization

Care management is seen as a promising approach to address the complex care needs of patients with multimorbidity. Predictive modeling based on insurance claims data is an emerging concept to identify patients likely to benefit from care management interventions. We aimed to identify and explore patterns of multimorbidity in primary care patients with high predicted risk of future hospitalizations in order to develop a primary care-based care management intervention. We conducted a retrospective cohort study to assess insurance claims data of 6026 patients from 10 primary care practices in Germany. We stratified the population by the predicted likelihood of hospitalization (LOH) using a diagnostic cost group-based case-finding software. Co-occurrence of chronic conditions in multimorbid patients with an upper-quartile LOH score was explored by extraction of mutually exclusive patterns. Predictive modeling identified multimorbid elderly patients with a high number of co-occurring chronic conditions (mean number 7.8 [SD 3.1]). Assessing co-occurrence of highly prevalent chronic conditions in 1407 multimorbid patients with upper-quartile LOH revealed 471 mutually exclusive patterns with low single frequencies. The observed prevalence significantly exceeded expected prevalence for patterns with causal comorbidity. Additionally, chronic pain (related to osteoarthritis) or depression could be identified as discordant co-occurring conditions in 80% (12/15) of the most common multimorbidity patterns. High-risk primary care patients suffer from heterogeneous individual patterns of co-occurring chronic conditions. Care management interventions will have to account for discordant co-occurring conditions such as osteoarthritis and depression.