Degree Of Comorbidity Research Articles

Comorbidity and the receipt of curative therapy for favorable-risk prostate cancer prior to and following the publication of PIVOT.

17 Background: On July 19, 2012, the Prostate Cancer Intervention versus Observation Trial (PIVOT) was published and reported that after a median follow up of 10 years, radical prostatectomy neither improved overall survival nor reduced prostate cancer (PC)-specific mortality in men with low-risk PC compared to watchful waiting. However, the trial’s applicability may be somewhat limited by the participants’ poorer-than-average overall health. This study aimed to evaluate the impact of the PIVOT by assessing practice patterns before and after its publication. Methods: Between October 1997 and May 2013, 6,818 men with low-risk (n = 5,081, 74.5%) or favorable intermediate-risk (N = 1,737, 25.5%) PC were treated with curative intent at the Chicago PC Foundation. We compared the proportions of these men with ≥2, 1, or 0 comorbid conditions, restricted to myocardial infarction, congestive heart failure, diabetes mellitus, and coronary artery disease. We assessed for a trend in these proportions by time tertile prior to the PIVOT’s publication and compared them one month following PIVOT to the final pre-publication time tertile. Results: Of 6,818 men treated with curative intent, 5,208 (76.5%), 1,307 (19.2%), and 293 (4.3%) had 0, 1, and ≥2 comorbidities, respectively. Prior to PIVOT, the proportion of men with the greatest comorbidity (≥2) increased by time tertile (3.5% vs. 4.2% vs. 5.4%; p = 0.002), while 1 month following publication, there was a decline in the proportion of men with the highest degree of comorbidity (5.4% vs. 2.9%; p = 0.05). In addition to the drop in men with greatest comorbidity, men treated following the publication of the PIVOT were also younger (median age 65.7 vs. 66.8 years; p = 0.04), more likely to be black or Hispanic (24.7% vs. 17.4%; p = 0.003), and more likely to have favorable intermediate than low-risk PC (36.1% vs. 28.4%; p = 0.007). Conclusions: Following the publication of the PIVOT, men with low or favorable intermediate-risk PC whose health was poorer than the national average were less likely to undergo curative treatment, whereas men at higher risk for harboring occult high grade PC despite favorable-risk indices were more likely to undergo curative treatment.

The burden of comorbidity in people with chronic kidney disease stage 3: a cohort study.

BackgroundMultimorbidity is a growing concern for healthcare systems, with many countries experiencing demographic transition to older population profiles. Chronic kidney disease (CKD) is common but often considered in isolation. The extent and prognostic significance of its comorbidities is not well understood. This study aimed to assess the extent and prognostic significance of 11 comorbidities in people with CKD stage 3.MethodsA prospective cohort of 1741 people with CKD stage 3 was recruited from primary care between August 2008 and March 2010. Participants underwent medical history, clinical assessment, blood and urine sampling. Comorbidity was defined by self-reported doctor-diagnosed condition, disease-specific medication or blood results (hemoglobin), and treatment burden as number of ongoing medications. Logistic regression was used to identify associations with greater treatment burden (taking >5 medications) and greater multimorbidity (3 or more comorbidities). Kaplan Meier plots and multivariate Cox proportional hazards models were used to investigate associations between multimorbidity and all-cause mortality.ResultsOne thousand seven hundred forty-one people were recruited, mean age 72.9 +/−9 years. Mean baseline eGFR was 52 ml/min/1.73 m2. Only 78/1741 (4 %) had no comorbidities, 453/1741 (26 %) had one, 508/1741 (29 %) had two and 702/1741 (40 %) had >2. Hypertension was common (88 %), 30 % had ‘painful condition’, 24 % anemia, 23 %, ischaemic heart disease, 17 % diabetes and 12 % thyroid disorders. Median medication use was 5 medications (interquartile range 3–8) and increased with degree of comorbidity. Greater treatment burden and multimorbidity were independently associated with age, smoking, increasing body mass index and decreasing eGFR. Treatment burden was also independently associated with lower education status. After median 3.6 years follow-up, 175/1741 (10 %) died. Greater multimorbidity was independently associated with mortality (hazard ratio 2.81 (95 % confidence intervals 1.72–4.58), p < 0.001) for 3 or more comorbidities vs 0 or 1).ConclusionsIsolated CKD was rare and multimorbidity the norm in this cohort of people with moderate CKD. Increasing multimorbidity was associated with greater medication burden and poorer survival. CKD management should include consideration of comorbidities.

Chronic diseases and geriatric syndromes: The different weight of comorbidity

BackgroundComorbidity is a relevant health determinant in older adults. Co-occurrence of several diseases and other age-associated conditions generates new clinical phenotypes (geriatric syndromes [GS] as falls, delirium etc.). We investigated the association of chronic diseases, alone or in combination, and GS in older adults receiving home care services in 11 European countries and one Canadian province. MethodsParticipants were cross-sectionally evaluated with the multidimensional assessment instrument RAI HC. We assessed 14 different diagnoses and 8 GS (pain, urinary incontinence, falls, disability, dizziness, weight loss, pressure ulcers and delirium). Adjusted mean number of GS per participant was calculated for groups of participants with each disease when occurring alone or with comorbidity. ResultsThe mean age of the 6903 participants was 82.2±7.4years and 4750 (69%) were women. Participants presented with an average of 2.6 diseases and 2.0 GS: pain (48%), urinary incontinence (47%) and falls (33%) were the most prevalent. Parkinson's disease, cerebrovascular disease and peripheral artery disease were associated with the highest number of GS (2.5, 2.3 and 2.2, respectively). Conversely, hypertension, diabetes, dementia, cancer and thyroid dysfunction were associated with the lowest number of GS (2.0 on average). For 9/14 examined diseases (hypertension, diabetes, dementia, COPD, heart failure, ischemic heart disease, atrial fibrillation, cancer and thyroid dysfunction) the number of GS increased with the degree of comorbidity. ConclusionsComorbidity and GS are prevalent in older adults receiving home care. Different diseases have a variable impact on occurrence of GS. Comorbidity is not always associated with an increased number of GS.

Abstract 11589: Comorbidity and Medication Use Are Risk Factors of Non-shockable Rhythm in Patients With Out-of-hospital Cardiac Arrest

Introduction: Non-shockable rhythm (NSR) is the most prevalent heart rhythm for both in- and out-of-hospital cardiac arrest (OHCA). While survival from OHCA patients with a shockable rhythm (SR) has increased over time, survival following NSR remains low. Thus, identification of risk factors for NSR is important to reduce mortality. We hypothesize that patients with NSR and SR are two disparate groups where patients with NSR are characterized by a high non-cardiac disease burden when compared to patients with SR. Methods: Using data from the nationwide Danish Cardiac Arrest Registry (2001–2012), we identified 33,617 OHCA patients ≥18 years old. The Danish National Registry of Patients was used to identify comorbidities while the National Prescription Registry was used to identify drug prescriptions (within 180 days). A multivariable logistic regression model was used to estimate odds ratios for risk factors associated with NSR. Results: Patients with NSR were characterized by a higher median age 71 years (IQR 60-81) vs. 67 years (IQR 58-77), higher proportion of women (38% vs. 21%), lower proportion of witnessed collapse (50% vs. 79%) and bystander CPR (27% vs. 50%) than patients with SR. A higher proportion of NSR occurred in private homes (77% vs. 58%) and time from recognition of OHCA to first rhythm analysis was longer: 13 min (IQR 7-22) vs. 9 min (IQR 6-14). In a fully adjusted model (patient-related and cardiac arrest-related characteristics included) a higher degree of comorbidity, psychiatric disease, chronic obstructive lung disease and the use of antidepressants, antipsychotics, anxiolytics, analgesics, corticosteroids, and antibiotics (within 14 days) where associated with NSR (Table). In contrast, the use of cardiovascular specific drugs and history of cardiovascular disease was associated with a lower risk of NSR. Conclusion: A history of non-cardiac disease and non-cardiac drug use are risk factors of NSR when compared to patients with SR.

Prevalence of mental health conditions after military blast exposure, their co-occurrence, and their relation to mild traumatic brain injury

Primary objectives: To measure common psychiatric conditions after military deployment with blast exposure and test relationships to post-concussion syndrome (PCS) symptoms and mild traumatic brain injury (mTBI) history.Research design: Cross-sectional.Methods and procedures: Service members or Veterans (n = 107) within 2 years of blast exposure underwent structured interviews for mTBI, post-traumatic stress disorder (PTSD) and multiple mood and anxiety diagnoses.Main outcomes and results: MTBI history and active PTSD were both common, additionally 61% had at least one post-deployment mood or anxiety disorder episode. Psychiatric diagnoses had a high degree of comorbidity. Most dramatically, depression was 43-times (95% CI = 11–165) more likely if an individual had PTSD. PCS symptoms were greater in those with post-deployment PTSD or mood diagnosis. However, neither mTBI nor blast exposure history had an effect on the odds of having PTSD, mood or anxiety condition.Conclusions: These findings support that psychiatric conditions beyond PTSD are common after military combat deployment with blast exposure. They also highlight the non-specificity of post-concussion type symptoms. While some researchers have implicated mTBI history as a contributor to post-deployment mental health conditions, no clear association was found. This may partly be due to the more rigorous method of retrospective mTBI diagnosis determination.

Prediction and prognostication of neurological deterioration in patients with acute ICH: a hospital-based cohort study

ObjectivePatients with intracerebral haemorrhage (ICH) are at high risk of neurological deterioration (ND). We aimed at establishing predictors of early ND (END) as well as late ND (LND) and at...

Evaluation of colonoscopy performance based on post-procedure bleeding complications: application of procedure complexity-adjusted model

High quality colonoscopy requires low complication rates. However in quality assurance, evaluation of individual colonoscopist complication rates is limited because complications are relatively rare events and there is variation in average procedure complexity. The aim of the study was to develop a quality system that adjusted for procedure complexity to monitor bleeding adverse events at both the screening center and colonoscopist levels. The study examined the risk factors for post-procedure bleeding from 130 831 colonoscopies conducted between August 2006 and January 2012. Binomial and logistic regression models were used to examine the risk of events against explanatory variables including age, sex, polyps resected, and polyp size. The models were used to produce a procedure-adjusted standardized adverse event ratio (PASAER) based on the ratio of the observed to expected number of adverse events. The primary outcome of interest was to identify centers that were outside a funnel plot outlier level of 99.8 % (3 SDs). Mulivariate models showed that the risk of bleeding was associated with largest resected polyp size, sex, polyp location, and degree of co-morbidity. These variables were used to calculate PASAERs for the 59 screening centers and 286 colonoscopists. The method highlighted one center with a high PASAER of 3.08 (32 observed compared with 10.4 expected events) and one with a low PASAER of 0.34 (10 observed compared with 29.8 expected events), which merited further investigation. The PASAER provided additional certainty that a crude adverse event rate was not confounded by procedure complexity, thus objectively identifying centers or colonoscopists that required further performance evaluation.

P6 – 2654: Clinical spectrum of cerebral palsy in Durban, South Africa

Objective To evaluate the clinical spectrum of cerebral palsy children in South Africa and their need. Methods The study was done in a tertiary children's outpatient hospital from July 2013 to December 2014. This was a retrospective, descriptive chart review of cerebral palsy patients. Background Few comprehensive studies have been done in South Africa. Results 30 children were analyzed. The average age was 5.8 years. The range was 2 to 13.5 years. The male to female ratio was 1.5:1. Children were classified according to the type of cerebral palsy. A paediatric neurologist, occupational therapist, physiotherapist, speech therapist, dietitian and psychologist examined them. 53% had bilateral spastic, 26.7% unilateral spastic, 13% dyskinetic, one ataxic and one mixed cerebral palsy. Common comorbidities (average 4 per child) were epilepsy, cognitive impairment, contractures, reflux, constipation, drooling and behaviour problems. Two had fractures and two precocious puberty. Twenty children (66%) had Epilepsy and twelve (40%) abnormal EEGs. There were 13 MRI brains done. The number of children with abnormal radiology, which included Ct brain, was 25 (83%). Two were unrecorded. Aetiology ranged from perinatal hypoxic ischaemic encephalopathy (43%), 13% brain malformations, 16.7% prematurity related complications, 23% post natal complications, including TB meningitis and jaundice, and one patient with no identified cause. Only nine children (30%) could walk. There was a high degree of disability with the GMFCS above 4 in 63%. The children were on an average of 4 medications and none were on Botulin toxin injections. Only 6 were in special schools. Conclusion The number of bilateral spastic cerebral palsy is still very high. The aetiology includes high number of preventable causes. There is a very high degree of comorbidity in children with cerebral palsy in South Africa and a high need for other therapy like botulin toxin, anti-drooling medication and special schools.

Does Hospital Reputation Influence the Choice of Hospital?

A number of recent empirical studies document significant effects of in-patient care quality indicators on the choice of hospital. These studies use either objective quality indicators based on quantitative figures, or if subjective reputation scores are used, scores based on the opinion of hospital market insiders. We contribute to the current debate by using a subjective reputation score resorting to patient perceptions and examine its impact on the choice of hospital of patients undergoing a coronary artery bypass graft (CABG) in Germany. Our results show that 76% of the patients value hospital reputation positively when choosing a hospital. Moreover, we find evidence for a trade-off between hospital reputation and travel time, i.e. a significant share of patients is willing to accept additional travel time to get a treatment in a hospital with better reputation. The average marginal effect for hospital reputation confirms this finding, since the magnitude of the effect strengthens for higher thresholds of travel time. The results are robust for different degrees of co-morbidities and admission status.

Aetiology and risk factors of community-acquired pneumonia in hospitalized patients in Norway.

In Norway, data on the aetiology of community-acquired pneumonia (CAP) in hospitalized patients are limited. The aims of this study were to investigate the bacterial aetiology of CAP in hospitalized patients in Norway, risk factors for CAP and possible differences in risk factors between patients with Legionnaire's disease and pneumonia because of other causes. Adult patients with radiologically confirmed CAP admitted to hospital were eligible for the study. Routine aerobic and Legionella culture of sputum, blood culture, urinary antigen test for Legionella pneumophila and Streptococcus pneumoniae, polymerase chain reaction detection of Chlamydophila pneumoniae, Mycoplasma pneumoniae and Bordetella pertussis from throat specimens, and serology for L. pneumophila serogroup 1-6 were performed. A questionnaire, which included demographic and clinical data, risk factors and treatment, was completed. We included 374 patients through a 20-month study period in 2007-2008. The aetiological agent was detected in 37% of cases. S. pneumoniae (20%) was the most prevalent agent, followed by Haemophilus influenzae (6%) and Legionella spp. (6%). Eight Legionella cases were diagnosed by urinary antigen test, of which four also had positive serology. In addition, 13 Legionella cases were diagnosed by serology. The degree of comorbidity was high. An increased risk of hospital-diagnosed Legionella pneumonia was found among patients with a diagnosis of chronic congestive heart failure. Our results indicate that S. pneumoniae is the most common bacterial cause of pneumonia in hospitalized patients, and the prevalence of Legionella pneumonia is probably higher in Norway than recognized previously.

Annual research review: The (epi)genetics of neurodevelopmental disorders in the era of whole-genome sequencing--unveiling the dark matter.

Neurodevelopmental disorders (NDDs) are defined by a wide variety of behavioural phenotypes, psychopathology and clinically informed categorical classifications. Diagnostic entities include intellectual disability (ID), the autism spectrum (ASD) and attention-deficit/hyperactivity disorder (ADHD). The aetiopathogenesis of these conditions and disorders involves an interaction between both genetic and environmental risk factors on the developmental trajectory. Despite their remarkable genetic heterogeneity and complexity of pathophysiological mechanisms, NDDs display an overlap in their phenotypic features, a considerable degree of comorbidity as well as sharing of genetic and environmental risk factors. This review aims to provide an overview of the genetics and epigenetic of NDDs. Recent evidence suggests a critical role of defined and tightly regulated neurodevelopmental programs running out of control in NDDs, most notably neuronal proliferation and migration, synapse formation and remodelling, as well as neural network configuration resulting in compromised systems connectivity and function. Moreover, the machinery of epigenetic programming, interacting with genetic liability, impacts many of those processes and pathways, thus modifying vulnerability of, and resilience to, NDDs. Consequently, the categorically defined entities of ID, ADHD and ASD are increasingly viewed as disorders on a multidimensional continuum of molecular and cellular deficiencies in neurodevelopment. As such, this range of NDDs displays a broad phenotypic diversity, which may be explained by a combination and interplay of underlying loss- and potential gain-of-function traits. In this overview, we discuss a backbone continuum concept of NDDs by summarizing pertinent findings in genetics and epigenetics. We also provide an appraisal of the genetic overlap versus differences, with a focus on genome-wide screening approaches for (epi)genetic variation. Finally, we conclude with insights from evolutionary psychobiology suggesting positive selection for discrete NDD-associated traits.

Chronic obstructive pulmonary disease in primary care: an epidemiologic cohort study from the Canadian Primary Care Sentinel Surveillance Network.

Chronic obstructive pulmonary disease (COPD) is mostly managed within primary care, but there is little Canadian evidence from this setting. This study was undertaken to determine the prevalence of physician-diagnosed COPD in primary care practices, and the degree of comorbidity with other chronic conditions, and to assess patterns of medication prescribing. The Canadian Primary Care Sentinel Surveillance Network is a national "network of networks" whose member practices use electronic medical records (EMRs). At the time of the study, it included data from 444 physicians from 10 networks in 8 provinces. We conducted an epidemiologic cohort study of all patients who had EMR data collected by the network at the end of 2012. Validated case-finding algorithms were used to identify cases of COPD. We used descriptive statistics and multivariate modelling analyses to calculate the prevalence of COPD, its association with key demographic factors and comorbidities, and patterns of medication prescribing. The observed prevalence of COPD was 4.0% (10043/250346), which represents a population prevalence of 3.4% using age-sex standardization. Comorbidity was common, with prevalence ratios ranging from 1.1 for the presence of a single comorbid condition to 1.9 for 4 or more comorbid conditions. Anticholinergic agents (63%), short- (48%) and long-acting (38%) β-agonists and inhaled corticosteroids (41%) were the most commonly used medications. The prevalence of physician-diagnosed COPD in Canadian primary care practices was similar to that reported in other practice-based studies at about 3%-4%. Most patients had comorbid conditions and were taking multiple medications. EMR data may be useful to assess both the epidemiology and management of COPD in primary care practices.

Validity of the Modified Charlson Comorbidity Index as Predictor of Short-term Outcome in Older Stroke Patients

The modified Charlson Comorbidity Index (MCCI) has been proposed as a tool for adjusting the outcomes of stroke for comorbidity, but its validity in such a context has been evaluated in only a few studies and needs to be further explored, especially in elderly patients. We aimed to retrospectively assess the validity of the MCCI as a predictor of the short-term outcomes in a cohort of 297 patients with first-ever ischemic stroke, older than 60 years, and managed according to a clinical pathway. The poor outcome (PO) at 1 month, defined as a modified Rankin Scale score of 3-6, was the primary end point. Furthermore, a new comorbidity index has been developed, specific to our cohort, according to the same statistical approach used for the original CCI. The MCCI showed a positive association with PO (odds ratio [OR] 1.62; 95% confidence interval [CI] .98-2.68) and mortality (hazard ratio [HR] 1.85; 95% CI .94-3.61), not statistically significant and totally dependent on its association with the severity of neurologic impairment at onset. The new comorbidity index showed, as expected, a significant association with the PO and mortality with higher point estimates of OR (2.74; 95% CI 1.64-4.59) and HR (2.73; 95% CI 1.51-4.94), but this association was also dependent on stroke severity and premorbid disability. Our results do not support the validity of the MCCI as a predictor of the short-term outcomes in elderly stroke patients nor could we develop a more valid index from the available data. This suggests the need for development of disease- and age-specific indexes, possibly according to a prospective design. In any case, initial stroke severity, a strong predictor of outcome, is associated with the degree of comorbidity.

Association of the Charlson Comorbidity Index with Renal Outcome and All-Cause Mortality in Antineutrophil Cytoplasmatic Antibody-Associated Vasculitis

The aim of this study is to determine the effect of comorbidity assessed by the Charlson comorbidity index (CCI) at the time of diagnosis on the outcome of antineutrophil cytoplasmatic antibody (ANCA) associated vasculitis (AAV).This is a longitudinal observational study of 30 consecutive patients with AAV who were diagnosed and followed from January 1996 to December 2011. The degree of comorbidity at diagnosis and last visit was scored according to the age-adjusted Charlson comorbidity index (CCI (a)). The post hoc analysis of increment in CCI during the study period and its predictive value for patient and renal survival were analyzed.Thirty patients with AAV were included in this study. A higher CCI (a) at diagnosis was positively correlated with higher activity score of AAV (P = 0.016), a CCI (a) >5, and with an increased risk for mortality (odds ratio 12; confidence interval 1.8–79.68, P = 0.014). The mean increment (Δ) of CCI (a) during the study period was 1.26 ± 2.03 (6–5). Correlation was found between lower Δ CCI (a) and chronic kidney disease (P = 0.036) and mortality (P = 0.002).Comorbidity at the time of diagnosis of AAV is associated with reduced patient and renal survival. We suggest including the CCI score in the assessment of patients with AAV at diagnosis and at disease relapse.

Allogeneic hematopoietic cell transplantation for acute myeloid leukemia during first complete remission: a clinical perspective.

Allogeneic hematopoietic cell transplantation (HCT) is the most potent therapy for preventing relapse of acute myeloid leukemia (AML). Although its efficacy is compromised by a high risk of treatment-related morbidity and mortality, an accumulating body of evidence has led to the general recommendation favoring allogeneic HCT from a matched sibling donor during first complete remission (CR1) for younger patients with cytogenetically intermediate- or high-risk AML. Over the past few decades, this field has seen a great many advancements. The indications for allogeneic HCT have been refined by taking into account the molecular profiles of leukemic cells and the degree of comorbidities. The introduction of high-resolution human leukocyte antigen-typing technology and advances in immunosuppressive therapy and supportive care measures have improved outcomes in alternative donor transplantation, while the parallel growth of unrelated donor registries and greater use of umbilical cord blood and haploidentical donors have considerably improved the chance of finding an alternative donor. The development of reduced-intensity and non-myeloablative conditioning has made it possible to receive allogeneic HCT for patients who might once have been considered ineligible due to advanced age or comorbidities. Thanks to these advances, the role of allogeneic HCT during CR1 has become progressively more important in the treatment of AML.

Extremes of body mass index and mortality among Asian peritoneal dialysis patients.

Extremes of body mass index and mortality among Asian peritoneal dialysis patients.

Late Life Depression and Anxiety in Four Types of Medicare Advantage Plans: Comorbidity with other Medical Diseases and Resource Utilization

Background: The prevalence of anxiety and depression and associated medical co-morbidities and costs has not been studied across different types of Medicare Advantage plans that vary in their level of utilization management and patient costs. Methods: A cross-sectional study of 74,290 older adults belonging to four different Universal American Medicare Advantage Plans was conducted, to estimate the period prevalence of depression and anxiety, the comorbidity between these disorders and major medical illnesses and associated costs. Results: The prevalence of anxiety or depression ranged from 14.5% to 18.8% across four types of Medicare Advantage plans, with HMO members less likely to be identified than members from fee-for-service or preferred provider organizations. Regardless of the type of plan, there was a high degree of comorbidity between depression and anxiety and other medical conditions, and higher utilization of services and costs in members with these disorders. Conclusions: A substantial prevalence of depression and anxiety disorders is present among older adult members of Medicare Advantage Plans and the presence of both disorders is associated with substantial medical comorbidity and costs. Clinicians in all care settings will encounter a substantial number of medically complex older adults with depression and anxiety, requiring close follow-up and coordination of care.

Separation Anxiety, Social Phobia and Generalized Anxiety Disorders in the Chilean Epidemiological Study of Children and Adolescents

The prevalence, correlates, comorbidity and service use of three anxiety disorders in a broad sample of Chilean children and adolescents is reported in this study. The disorders studied were Separation anxiety (SAD), Generalized anxiety (GAD) and Social anxiety. Data were obtained from an extensive epidemiological study of psychiatric disorders in the community. DSM-IV diagnoses were assessed by means of the DISC-IV interview, demographic and family variables through the family assessment device and family history screen instrument, as well as the services provided by the Service Assessment Instrument. Prevalence with significant impairment for Separation anxiety was 4.8%, for social phobia, 3.7%, for generalized anxiety 3.2%, and 8.3% for any of the three disorders. Associated risk variables were as follows: low family income, family psychopathology, living with only one parent, maltreatment. A positive evaluation of family functioning was a protective factor against disorders. A high degree of comorbidity between the three anxiety disorders and with other groups of disorders was observed. The services were used by 22.3% of the children and adolescents diagnosed with any of the three anxiety disorders and within them, school based services were the most used. Findings are discussed and compared with other studies

Resources allocation and health care needs in diabetes care in Danish GP clinics

BackgroundIn several countries, morbidity burdens have prompted authorities to change the system for allocating resources among patients from a demographic-based to a morbidity-based casemix system. In Danish general practice clinics, there is no morbidity-based casemix adjustment system. AimThe aim of this paper was to assess what proportions of the variation in fee-for-service (FFS) expenditures are explained by type 2 diabetes mellitus (T2DM) patients’ co-morbidity burden and illness characteristics. Methods and dataWe use patient morbidity characteristics such as diagnostic markers and co-morbidity casemix adjustments based on resource utilisation bands and FFS expenditures for a sample of 6706 T2DM patients in 59 general practices for the year 2010. We applied a fixed-effect approach. ResultsAverage annual FFS expenditures were approximately 398 euro per T2DM patient. Expenditures increased progressively with the patients’ degree of co-morbidity and were higher for patients who suffered from diagnostic markers. A total of 17–25% of the expenditure variation was explained by age, gender and patients’ morbidity patterns. ConclusionT2DM patient morbidity characteristics are significant patient related FFS expenditure drivers in diabetes care. To address the specific health care needs of T2DM patients in GP clinics, our study indicates that it may be advisable to introduce a morbidity based casemix adjustment system.

Reduction of Bulimia Nervosa Symptoms After Psychostimulant Initiation in Patients With Comorbid ADHD: Five Case Reports

Studies reveal a higher occurrence of bulimia nervosa (BN) in patients with attention deficit/hyperactivity disorder (ADHD) compared to controls. Due to this high degree of comorbidity, some clinicians have used psychostimulants in this population. The goal of this article is to describe five patients with comorbid BN and ADHD and their responses to a course of psychostimulants. After medication initiation, all five patients experienced a decrease in binge/purging and an improvement in ADHD symptoms. Overall, the medications were well tolerated. Possible mechanisms underlying the relationship between ADHD and BN, and words of caution are discussed. The need for clinical trials to further evaluate the efficacy of psychostimulants in this population is warranted.