Management Of Multiple Chronic Conditions Research Articles

Recent Applications of PLGA in Drug Delivery Systems.

Poly(lactic-co-glycolic acid) (PLGA) is a widely used biodegradable and biocompatible copolymer in drug delivery systems (DDSs). In this article, we highlight the critical physicochemical properties of PLGA, including its molecular weight, intrinsic viscosity, monomer ratio, blockiness, and end caps, that significantly influence drug release profiles and degradation times. This review also covers the extensive literature on the application of PLGA in delivering small-molecule drugs, proteins, peptides, antibiotics, and antiviral drugs. Furthermore, we discuss the role of PLGA-based DDSs in the treating various diseases, including cancer, neurological disorders, pain, and inflammation. The incorporation of drugs into PLGA nanoparticles and microspheres has been shown to enhance their therapeutic efficacy, reduce toxicity, and improve patient compliance. Overall, PLGA-based DDSs holds great promise for the advancement of the treatment and management of multiple chronic conditions.

Addressing Healthcare Utilization and Costs for Older Adults with Limited Mobility Through a Multidisciplinary Home-Based Primary Care Program.

Home-based primary care (HBPC) has shown promise in the management of multiple chronic conditions for patients who are homebound or who have limited mobility. The objective of this study was to implement and evaluate an HBPC program that integrates the services of clinical pharmacists and community aging services providers in a community-based setting. Mountain Area Health Education Center's (MAHEC) HBPC program brought together an interdisciplinary team including medical providers, pharmacists, and community aging services providers to conduct home visits with older adults (age 50+). A single-arm, prepost analysis was conducted to determine differences from the year before program enrollment to the year postenrollment. We examined the frequency of health care visits, high-cost health care utilization (emergency department [ED] utilization and hospitalizations), and health care costs. Descriptive statistics characterized the study population and outcomes. Fisher's Exact Tests were used to determine if there was a significant difference between years. There were 130 home visits with 62 patients enrolled in the program. The Medicare Annual Wellness Visit (AWV) was completed for 32 (51.6%) patients. There were 13 (21.0%) and 12 (19.4%) individuals who had at least 1 ED visit and hospitalization, respectively, pre-enrollment as compared with 8 (12.9%) and 9 (14.5%) individuals postenrollment (p-value = 0.05, p-value = 0.06). During the postenrollment year, patient enrollees had an average per-member-per-month (PMPM) cost of $1567.96 as compared with $3053.21 in the year prior. Pharmacist and community agency services-integrated HBPC was implemented in the community setting. There was a decrease in high-cost health care utilization and total health care expenditures for patients as compared with the previous year.

Relationships between enabling services use and access to care among adults with cardiometabolic risk factors: findings from the 2014 National Health Center Patient Survey

BackgroundCommunity health centers (CHCs) provide comprehensive primary and preventive care to medically underserved, low-income, and racially/ethnically diverse populations. CHCs also offer enabling services, non-clinical assistance to reduce barriers to healthcare due to unmet social and material needs, to improve access to healthcare and reduce health disparities. For patients with modifiable cardiometabolic risk factors, including obesity, hypertension, and diabetes, enabling services may provide additional support to improve disease management. However, little is known about the relationship between enabling services and healthcare accessibility and utilization among patients with cardiometabolic risk factors.MethodsThis study uses data from the 2014 Health Center Patient Survey to examine the relationship between enabling services use and delayed/foregone care, routine check-ups, and emergency room visits, among adult community health center patients in the United States with cardiometabolic risk factors (N = 2358). Outcomes of enabling services users were compared to nonusers using doubly robust propensity score matching methods and generalized linear regression models.ResultsOverall, enabling service users were 15.4 percentage points less likely to report delayed/foregone care and 29.4 percentage points more likely to report routine check-ups than nonusers. Enabling service users who lived in urban areas, younger and middle-aged adults, and those with two cardiometabolic risk factors were also less likely to report delayed/foregone care and/or more likely to report routine check-ups in comparison with nonusers. However, among adults with three or more cardiometabolic risk factors, enabling services use was associated with a 41.3 percentage point increase in emergency room visits and a 7.6 percentage point decrease in routine check-ups.ConclusionsThe findings highlight the value in utilizing enabling services to improve timeliness and receipt of care among CHC patients with heightened cardiometabolic risk. There is a need for targeting high-risk populations with additional enabling services to support management of multiple chronic conditions.

Self-reported Physical Health as a Mediator of the Effects of BMI on Depression among People with Multiple Chronic Conditions

Background: The current study examined whether the association between body mass index (BMI) and symptoms of depression is mediated by self-reported physical health among Chinese people with multiple chronic conditions (MCCs). Methods: This was a secondary analysis based on a previous cross-sectional survey using the Hospital Anxiety and Depression Scale (HADS) and Short Form-12 (SF-12). A convenience sample of Chinese people with MCCs (n = 351) was recruited and a mediation effect model using SPSS PROCESS was employed. Results: The results showed that self-reported physical health acted as a full mediator in the association between BMI and depression only for men with MCCs. Conclusions: The findings of this study suggest that decreased physical health should be of primary importance in the management of MCCs. Further intervention addressing weight control could be a strategy of particular interest for improving the mental health of people with MCCs.

Coping with Multiple Chronic Conditions in the Family Context: A Meta-Synthesis.

This study was to collect, synthesize, and interpret the current qualitative evidence from studies that investigated family coping among people with multiple chronic conditions (MCCs). A meta-synthesis approach was used to report this study. A systematic search was performed in five electronic databases, including CINAHL, EMBASE, PsycINFO, Web of Science, and PubMed from January 2000 to December 2020. The PRISMA flow chart and Joanna Briggs Institute Qualitative Assessment and Review Instrument checklist are integrated into the meta-synthesis. A total of ten eligible studies including data from 381 participants were identified. Three meta-themes were identified in the synthesis: (1) family role maintenance in MCCs management, (2) coping as a family, and (3) be frustrated with family interactions. This meta-synthesis indicated the importance of maintaining social roles and family support within family interactions for coping with MCCs. It also demonstrated the frustrations in the family coping process experienced by people with MCCs. Health care professionals should understand the interactions between people with MCCs and their family members that may impact people's coping. Such an understanding may contribute to the development of supportive programs such as family-based interventions for people with MCCs.

Abstract 16318: Care Dyadic Types in Patients With Multiple Chronic Conditions and Their Caregivers

Introduction: Multiple Chronic Conditions (MCC) are highly prevalent in patients with cardiovascular diseases. Patients’ informal caregivers play an essential role to achieve both patient and caregiver health outcomes. Four Care Dyadic Types (DTs) of caregiver-patient relationships were previously described in heart failure depending on who is responsible for most of the care: patient-oriented, caregiver-oriented, collaborative, and incongruent (i.e., disagreement on who is responsible for the care). Since DTs in MCC were not described yet, this study aimed to describe the DTs in MCC management, and to identify the patient and caregiver characteristics associated with each type of DT. Methods: We conducted a cross-sectional study enrolling 541 dyads in outpatient settings in Italy. Patients were included in the study if they were ≥65 years old, affected by at least two chronic conditions, and had an informal caregiver ≥18 years old. The Dyadic Symptom Management Type scale was used to assess DTs. Logistic regression analysis was used to identify the characteristics associated with each DT. Results: Most patients and caregivers were female with a mean age of 76.54 (SD 7.23) years and 52.71 (SD 15.06) years, respectively. One third of the patients had heart failure. Younger patients with better cognitive status, fewer comorbidities, better relationship with their caregivers and male caregivers with a lower burden were associated with patient-oriented DT (14.2%, R 2 0.407). Older patients and caregivers with a higher burden were associated with caregiver-oriented DT (11.6%, R 2 0.388). Patients with more comorbidities, better relationship with their caregivers, and female caregivers with lower burden, perceiving strong social support, were associated with collaborative DT (58.8%, R 2 0.097). Caregivers with lower income, more frequently employed, providing more caregiving hours, and having a lower burden were associated with incongruent DT (15.4%, R 2 0.075). Conclusion: Different DTs were described in MCCs identifying specific patients and caregivers’ associated characteristics. This is helpful to classify the dyads and to tailor interventions aimed to empower patients and caregivers in MCCs.

Enhanced care planning and clinical-community linkages versus usual care to address basic needs of patients with multiple chronic conditions: a clinician-level randomized controlled trial

BackgroundMany patients with poorly controlled multiple chronic conditions (MCC) also have unhealthy behaviors, mental health challenges, and unmet social needs. Medical management of MCC may have limited benefit if patients are struggling to address their basic life needs. Health systems and communities increasingly recognize the need to address these issues and are experimenting with and investing in new models for connecting patients with needed services. Yet primary care clinicians, whose regular contact with patients makes them more familiar with patients’ needs, are often not included in these systems.MethodsWe are starting a clinician-level cluster-randomized controlled trial to evaluate how primary care clinicians can participate in these community and hospital solutions and whether doing so is effective in controlling MCC. Sixty clinicians in the Virginia Ambulatory Care Outcomes Research Network will be matched by age and sex and randomized to usual care (control condition) or enhanced care planning with clinical-community linkage support (intervention). From the electronic health record we will identify all patients with MCC, including cardiovascular disease or risks, diabetes, obesity, or depression. A baseline assessment will be mailed to up to 50 randomly selected patients for each clinician (3000 total). Ten respondents per clinician (600 patients total) with uncontrolled MCC will be randomly selected for study inclusion, with oversampling of minorities. The intervention includes two components. First, we will use an enhanced care planning tool, My Own Health Report (MOHR), to screen patients for health behavior, mental health, and social needs. Patients will be supported by a patient navigator, who will help patients prioritize needs, create care plans, and write a personal narrative to guide the care team. Patients will update care plans every 1 to 2 weeks. Second, we will create community-clinical linkage to help address patients’ needs. The linkage will include community resource registries, personnel to span settings (patient navigators and a community health worker), and care team coordination across team members through MOHR.DiscussionThis study will help inform efforts by primary care clinicians to help address unhealthy behaviors, mental health needs, and social risks as a strategy to better control MCC.Trial registrationClinicalTrials.gov: NCT03885401. Registered on 19 September 2019.

Facilitators and barriers of managing patients with multiple chronic conditions in the community: a qualitative study

BackgroundApproximately one-third of all adults worldwide are diagnosed with multiple chronic conditions (MCCs). The literature has identified several challenges facing providers and patients coping with managing MCCs in the community, yet few studies have considered their viewpoints in combination. A qualitative study involving healthcare providers and users was thus conducted to examine facilitators and barriers of managing patients with MCCs in the community in Singapore.MethodsThis study involves 26 semi-structured interviews with 10 physicians, 2 caregivers and 14 patients seeking treatment in the polyclinics that provide subsidised primary care services. Topic guides were developed with reference to the literature review, Chronic Care Model (CCM) and framework for patient-centred access to healthcare.ResultsDespite the perceived affordability and availability of the support system, some patients still encountered financial difficulties in managing care. These include inadequacy of the nation-wide medical savings scheme to cover outpatient treatment and medications. Half of healthcare users did not know where to seek help. While patients could access comprehensive services in polyclinics, those who did not visit the clinics might not receive timely care. Furthermore, patients reported long consultation waiting time.Physicians were able to propose and drive quality improvement projects to improve care quality. However, there were challenges to delivering safe and quality care with limited consultation duration due to the need to manage high patient load and waiting time, inadequate communication with specialists to coordinate care, and resource constraints in managing complex patients.Although providers could equip patients with self-management and lifestyle-related guidelines, patients’ actions are influenced by multiple factors, including work requirements, beliefs and environment.ConclusionsThere were barriers on care access, delivery and self-management. It is crucial to adopt a whole-of-society approach involving individuals, community, institutions and policymakers to improve and support MCC management. This study has also highlighted the importance of considering the different viewpoints of healthcare providers and users in policy formulation and community care planning.

Abstract WP217: A New Index for Multiple Chronic Conditions Predicts Post-Stroke Functional Outcome: A Machine Learning Approach in the Brain Attack Surveillance in Corpus Christi Project

Introduction: Multiple chronic conditions (MCC) diminish the pre-stroke reserve that aids post-stroke adaptation and recovery. Through machine learning, we developed a MCC index that integrates pre-stroke comorbid conditions, functional and cognitive factors, as well as their interactions, to predict post-stroke functional outcome (FO) in a bi-ethnic, population-based cohort study. Methods: Ischemic stroke patients (2008-2017) were interviewed at baseline and 90 days. FO score (range 1-4, higher scores worse) at 90 days was measured by averaging 22 activities of daily living (ADL)/instrumental activities of daily living (IADL) and dichotomizing the score into favorable (1-3) and unfavorable FO (>3, a lot of difficulty with ADL/IADLs). Multiple linear regression was fit with a Lasso penalty to select predictors among 22 chronic conditions from ICD codes and medical records, pre-stroke function, cognitive impairment, social support, marital status, depression, age, initial stroke severity (NIHSS) and all pairwise interactions. We developed an MCC index by weighting selected predictors using β-coefficients. Adjusted R 2 , discrimination and calibration of the model were assessed. Results: Among 1,035 stroke survivors, 69% were Mexican American, 51% were female, mean age was 68 (SD=12), and median initial NIHSS was 4 (IQR:2-8). Median FO score was 2.36 (IQR:1.55-3.41); 32% had unfavorable FO. The final model contained the pre-stroke modified Rankin Score (mRS), initial NIHSS, age, congestive heart failure (CHF), weight loss, diabetes, other neurological disease, initial NIHSS х pre-stroke mRS, dementia х age, CHF х renal failure and pre-stroke mRS х history of stroke/TIA, which explained 44% of variability in FO score. The MCC index was well calibrated (p=0.28) and predicted unfavorable FO well (c-statistic, 0.84) in the internal validation dataset. Conclusion: A new MCC assessment tool was developed and validated to improve the prediction of post-stroke FO. Weight loss, other neurological disease and interactions between MCC were discovered as novel predictors. Efforts to improve stroke prognosis may benefit from a better understanding, prevention and management of MCC in population at high risk for stroke.

CANCER PREVALENCE AND THE ROLE OF MULTIMORBIDITY AMONG OLDER ADULTS: USING NHANES 2011-2016

Cancer risk increases as age, understanding the potential risk factors of cancer is essential for cancer prevention. Biological and epidemiologic studies suggest relationships between individual chronic conditions and increased cancer risk. However, limited researches have analyzed the association between multimorbidity (simultaneous presentation of two or more chronic diseases) and cancer. The current study is aimed to evaluate whether having multimorbidity is associated with increased all-site and site-specific cancer prevalence among older adults. Data of 5,200 older adults aged 55 years and older who participated in the 2011-2016 National Health and Nutrition Examination Survey (NHANES) were included in the study. Single and multiple logistic regression models were used to evaluate the associations between multimorbidity and cancer. 3,623 (70%) individuals in our study were identified as having multimorbidity and 992 (19%) individuals were diagnosed with cancer. After adjusting for demographic covariates and smoking status, having multimorbidity was significantly associated with having all-site cancer (AOR: 1.57; 95% CI: 1.25 – 1.98) and lung cancer (AOR: 8.91; 95% CI: 1.51 - 52.73). Multimorbidity was associated with increased odds of having cancers among older adults. Our findings add to the evidence suggesting the potential relationships between multimorbidity and cancer. Future longitudinal studies are needed to examine the biological mechanisms and temporality of the association. If the association between multimorbidity and cancer is affirmed, it could have substantial implications in public health, as management of multiple chronic conditions could also advantage cancer prevention among older adults.

HEALTHCARE PROVIDERS’ EXPERIENCES IN CARING FOR OLDER ADULTS WITH MULTIPLE CHRONIC CONDITIONS

The management of multiple chronic conditions (MCC) in older adults living in the community is complex. Little is known about the experiences of interdisciplinary primary care and home providers who care for this vulnerable group. The aim of this study was to explore the experiences of healthcare providers in managing the care of community-living older adults with MCC and to highlight their recommendations for improving care delivery for this group. A qualitative interpretive description design was used. A total of 42 healthcare providers from two provinces in Canada participated in semi-structured interviews. Participants represented diverse disciplines (e.g., physicians, nurses, social workers, personal support workers) and settings (e.g., primary care and home care). Thematic analysis was used to analyze interview data. The experiences of healthcare providers managing care for older adults with MCC were organized into six major themes: (1) managing complexity associated with MCC, (2) implementing person-centred care, (3), involving and supporting family caregivers, (4) using a team approach for holistic care delivery, (5) encountering rewards and challenges in caring for older adults with MCC, and (6) recommending ways to address the challenges of the healthcare system. Healthcare providers highlighted the need for a more comprehensive integrated system of care to improve care management for older adults with MCC and their family caregivers. Specifically, they suggested increased care coordination, more comprehensive primary care visits with an interprofessional team, and increased home care support.

Lung cancer risk and the inhibitors of angiotensinconverting enzyme: A mini-review of recent evidence

Angiotensin-converting enzyme inhibitors (ACEIs) are among the most widely prescribed antihypertensive medications. They are indicated in the management of multiple chronic conditions including hypertension, diabetes mellitus and heart failure. ACEIs prevent angiotensin II (Ang II) production and bradykinin catabolism leading to vasodilation and reduction of arterial blood pressure. Recently, the role of the reninangiotensin system (RAS) inhibitors has become the subject of scrutiny in the treatment of cancer metastasis. The administration of ACEIs, however, has been described to be accompanying with carcinogenic effects.

Effective Preventive Care Management of Multiple Chronic Conditions

Clinical practice guidelines do not sufficiently address the needs of patients with multiple chronic conditions (MCC) as these guidelines focus on single disease management and ignore unique patient-specific conditions. As a result, a non-personalized approach for the management of the patients with MCC leads to adverse events and increases the financial burden on the health care system as over 150 million Americans experience MCC. To this end, we develop a stochastic modeling framework to personalize the management of MCC and provide an exact solution algorithm. We consider the optimal management of preventive care for an index disease (e.g., breast cancer, colorectal cancer, HIV, etc.) while accounting for the existence of a chronic condition (e.g., hypertension, diabetes, Alzheimer's disease, etc.) Our modeling framework is particularly useful for the cases where the chronic condition affects the risk of the index disease. In a case study using real breast cancer epidemiology data, we demonstrate how our modeling framework can be used to personalize breast cancer screening for women with type 2 diabetes. In addition to providing a personalized breast cancer screening schedule for diabetic women, we find some important policy insights that were not previously recognized by the medical community. More specifically, we find that compared to non-diabetic women, diabetic women should be screened less aggressively but screening should end at similar ages. We also find that adherence to the optimal screening policy is more crucial for diabetic women compared to non-diabetic women. Our main insight on screening recommendations also has important resource implications as it leads to fewer screening mammograms. That is, compared to the current national breast cancer screening guidelines, the optimal breast cancer screening policy for diabetic women could save the health care system approximately 2.6 million mammograms annually which translates to $405 million of annual cost savings.

National Clinical Graduate Nursing Faculty: Management of Multiple Chronic Conditions.

The purpose of this project is to compare clinical graduate nursing faculty self-perceived knowledge with actual knowledge on the management of symptomatic multiple chronic conditions (MCCs) through a psychometrically reliable and valid 46-item objective examination. Methodology included three separate e-mail communications to more than 800 U.S.-based graduate nursing school or program chairs, deans, or directors encouraging faculty participation. One hundred and six respondents initiated the survey and over half of the participants withdrew from completing in its entirety, making it difficult to correlate self-perceived knowledge with actual knowledge. The results, however, show an overall mean score of below average pass rate. This study has been performed in undergraduate, graduate, and clinical graduate nursing faculty-suggesting a serious concern in clinical nursing education and clinical practice to meet the complex care needs of the largest, fastest-growing, and costliest U.S. patient population-those with MCCs.

Occupational Therapy and Management of Multiple Chronic Conditions in the Context of Health Care Reform.

One in four individuals living in the United States has multiple chronic conditions (MCCs), and the already high prevalence of MCCs continues to grow. This population has high rates of health care utilization yet poor outcomes, leading to elevated concerns about fragmented, low-quality care provided within the current health care system. Several national initiatives endeavor to improve care for the population with MCCs, and occupational therapy is uniquely positioned to contribute to these efforts for more efficient, effective, client-centered management of care. By integrating findings from the literature with current policy and practice, we aim to highlight the potential role for occupational therapy in managing MCCs within the evolving health care system.

Barriers and facilitators to managing multiple chronic conditions: a systematic literature review.

The prevalence of multiple chronic conditions (MCC) is increasing, creating challenges for patients, families, and the health care system. A systematic literature search was conducted to locate studies describing patient's perceptions of facilitators and barriers to management of MCC. Thirteen articles met study inclusion criteria. Patients reported nine categories of barriers including financial constraints, logistical challenges, physical limitations, lifestyle changes, emotional impact, inadequate family and social support, and the complexity of managing multiple conditions, medications, and communicating with health care providers. Four facilitators were found, including health system support, individualized care education and knowledge, informal support from family and social systems, and having personal mental and emotional strength. Existing research on management of MCC from the patient's perspective is limited. Interventions are needed to improve management practices with particular attention to the knowledge and skills required by this unique population.

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Strategic Framework on Multiple Chronic Conditions Will Influence NP Practice

PhD, NP T he Affordable Care Act, with its emphasis on disease prevention, brings new attention to how US healthcare is provided and focuses attention on nurse practitioners (NPs) as an important component of the healthcare system. This new focus has stressed the importance of learning how to care for our patients in a better way, particularly those who have chronic illnesses. A close examination of US healthcare statistics reveals that more than a quarter of all Americans—and 2 of 3 older Americans—have multiple chronic conditions. Treatment for individuals with chronic illnesses accounts for 66% of the country’s healthcare budget, whether it is public or privately funded. These numbers of individuals with chronic illnesses are expected to rise as the number of older Americans increases. An analysis of current healthcare shows that the system is largely designed to treat one disease or condition at a time. This is an antiquated treatment format, often resulting from the high utilization of specialists who focus on one disease entity and where coordination of overall care is often missing or fragmented. As the number of chronic conditions that a person has increases, so do the risks of drug and physiologic complications, including adverse drug events, duplication or gaps in services, unnecessary hospitalizations, and confusion caused by conflicting medical advice. The US Health and Human Services recently issued the report “Strategic Framework on Multiple Chronic Conditions.” This report is a strong indictment of the current healthcare system and a call for change. (See http://www.hhs.gov/news/press/2010pres/12/20101214a. html for more information about this report.) A press release from HHS indicates the report outlines a new strategic framework to be coordinated by the agency. The report claims the new framework is designed to reduce the risks of complications and improve the overall health status of individuals with multiple chronic conditions. The framework is meant to provide more information and better tools to help health professionals and patients learn how to better coordinate and manage care. The framework also aims to facilitate research to improve oversight and care of patients. As such, all healthcare providers should learn about the new framework and how they will fit into the impending system. The report emphasizes, “The management of multiple chronic conditions has major cost implications for both the country and individuals. Increased spending on chronic diseases is a key factor driving the overall growth in spending in the Medicare program.” Especially during these times of fiscal constraint, individuals with multiple chronic conditions face increased out-of-pocket costs for their care, prescriptions, and support services. The integration and coordination of care for this Medicare population is foundational if better care, lower costs, greater efficiency, and quality are to be realized. NPs need to be adequately prepared if they are to participate fully in the opportunities to keep chronic conditions from occurring in the first place and to improve the quality of life for patients who have them. Nurse practitioner educational programs must be responsive to making changes in how to care for patients with chronic diseases. In this effort, JNP is timely in our focus throughout 2011 on the management of chronic diseases.