Management Of Multimorbidity Research Articles

Variant connective tissue (joint hypermobility) and dysautonomia are associated with multimorbidity at the intersection between physical and psychological health.

The symptoms of joint hypermobility extend beyond articular pain. Hypermobile people commonly experience autonomic symptoms (dysautonomia), and anxiety or related psychological issues. We tested whether dysautonomia might mediate the association between hypermobility and anxiety in adults diagnosed with mental health disorders and/or neurodevelopmental conditions (hereon referred to as patients), by quantifying joint hypermobility and symptoms of autonomic dysfunction. Prevalence of generalized joint laxity (hypermobility) in 377 individuals with diagnoses of mental health disorders and/or neurodevelopmental conditions was compared to prevalence recorded in the general population. Autonomic symptom burden was compared between hypermobile and non-hypermobile patients. Mediation analysis explored relationships between hypermobility, autonomic dysfunction, and anxiety. Patient participants had elevated prevalence of generalized joint laxity (38%) compared to the general population rate of 19% (odds ratio: 2.54 [95% confidence interval: 2.05, 3.16]). Hypermobile participants reported significantly more autonomic symptoms. Symptoms of orthostatic intolerance mediated the relationship between hypermobility and diagnosis of an anxiety disorder. Patients with mental health disorders and/or neurodevelopmental conditions have high rates of joint hypermobility. Accompanying autonomic dysfunction mediates the association between joint hypermobility and clinical anxiety status. Increased recognition of this association can enhance mechanistic understanding and improve the management of multimorbidity expressed in physical symptoms and mental health difficulties.

One size does not fit all: Enabling choice and patient-centred care in a chronic pain rehabilitation service

Purpose: Guidelines recommend that management of multi-morbidity, including symptom complexes such as chronic pain, should develop an individualised management plan taking a person's needs and preferences into account. The NHS Plan calls for an end to one size fits all and recommends differentiated, personalised care to reduce inequalities for people with long term conditions. Specialist pain management services have tight referral criteria, meaning that individuals may be denied treatment. A process audit was conducted in order to determine whether patients accessed treatment equitably in a pain rehabilitation service.

The effects of low-impact moderate-intensity stepping exercise on fatigue and other functional outcomes in older adults with multimorbidity: A randomized controlled trial

ObjectivesFatigue is highly prevalent among older adults with multimorbidity. As the World Health Organization advocates for strategies that improve the functional status of this aged cohort, this study examined the effects of a low-impact moderate-intensity exercise program on their fatigue levels and related functional health outcomes. Methods and MaterialsA multi-site clinical trial randomized 124 community-dwelling older adults with multimorbidity [mean age: 78.1 years (SD: 7.0); female: 83.8%] to a low-impact exercise program (intervention) group or a health education (control) group. The exercise program was designed to address fatigue-associated low energy levels, and consisted of thrice-weekly low-impact stepping exercises that were progressively increased from low intensity to moderate intensity over a 12-week period, using group-based practice to encourage engagement. The Multidimensional Fatigue Inventory, FRAIL Scale, International Physical Activity Questionnaire, the two-minute walking test, and Profile of Mood States (short-from) were administered at baseline, post-intervention, and 12 weeks thereafter. ResultsGeneralized estimating equation showed that the intervention group reported greater decreases in fatigue and frailty, and greater improvements in physical activity level, exercise tolerance, and mood status than the control group. The positive effects of the intervention on most of these outcomes were sustained over the two post-test endpoints. Discussion and implicationsThe low-impact stepping-based moderate-intensity exercise program is effective to improve fatigue and functional outcomes in older adults with multimorbidity. As it can be challenging to engage the fatigued older adults in exercise training, this study adds insights to inform community-based care approach for multimorbidity management.

"How I Can Help Me": Self-Care Priorities and Structural Pressures Among Black Older Adults With Diabetes.

Disparities in type 2 diabetes mellitus (diabetes) represent an ongoing public health challenge. Black older adults are at high risk of diabetes and diabetes' complications. Diet, physical activity, and medication can control these risks, yet disease rates remain elevated. Utilizing an intersectionality framework, we seek to extend understanding of the social dimensions of diabetes through an examination of the diabetes self-care process from the perspective of Black older adults. This project involved a thematic analysis of diabetes illness narrative interviews with Black participants (N = 41) in our National Institute on Aging-funded study of diabetes. In a narrative approach, the participant communicates the significance of actions and events. The findings suggest that diabetes self-care involves interconnected struggles across four domains of care: (1) multimorbidity management, (2) financial well-being, (3) family support, and (4) formal health care. Black older adult self-care reflects an active process of pursuing meaningful social goals and critical health needs. An intersectional framework, however, reveals the ongoing histories of inequity that shape this process. Further intervention to address the racist policies and practices found in Black older adults' communities and clinical care is needed to make true progress on diabetes disparities.

11.D. Workshop: Global Burden of Multimorbidity: from Epidemiology to Policy

Abstract Background Ageing societies have become a growing phenomenon globally. One of the most frequent consequences of ageing is an accumulation of diseases, hence living with multiple conditions in advanced age has become the norm rather than the exception. Multimorbidity is usually defined as the coexistence of two or more chronic conditions. It is associated with increased disability and functional decline, polypharmacy, reduced quality of life, and increased health care costs. People with multimorbidity represent as well the most vulnerable population subgroup to severe consequences from the current pandemic. Aim The overall aim of the workshop will be to facilitate cross-national discussion about ongoing and completed research in public health and primary care, and to identify the next steps for key areas of multimorbidity research and policy. The specific objectives of this workshop will be three-fold: to discuss progress and findings that have already been achieved in respective jurisdictions and countries of the participating speakers; to facilitate collaboration through brainstorming and discussion to identify strategies to move multimorbidity research and policy forward; and to create concrete plans to ensure advances in multimorbidity research and knowledge can be achieved through cross-national partnerships, with potential implications for the prevention, clinical management and public health policies regarding multimorbidity. Structure The workshop will consist of four presentations by leading scholars in the field of multimorbidity research and policy. Specifically, Dr. Kathryn Nicholson (Western University, Canada) will provide a global overview on the epidemiology of multimorbidity and underlying risk factors and their impact on policy, across different world regions; Prof. Dr. Marjan van den Akker (Goethe University, Germany) will discuss different models of care as well as major health care challenges in the management of multimorbidity in primary care with focus on interactions (disease-disease, treatment-treatment, and treatment-disease) extrapolated from (disease specific) guidelines and the feasibility to apply these guidelines for and with patients who have multimorbidity; Dr. Iveta Nagyova (PJ Safarik University, Slovakia) will address the potential for behavioural interventions to improve the cost-effectiveness of public health policy for the prevention and management of multimorbidity; finally, Dr. Gauden Galea (WHO) will provide a global perspective on current public health policies to tackle the growing burden of multimorbidity both in high-income and low-resource settings. Following the presentations by the four speakers, an open discussion will give attendees the possibility to share their opinions regarding challenges and opportunities in the prevention, management and policy of multimorbidity in their respective jurisdictions, with the ultimate goal to foster cross-national partnerships. Key messages The integration of public health and primary care is crucial to improve both prevention and clinical management of multimorbidity. There is a need for collaborative international partnerships, supported by patient and caregiver involvement in research.

Multimorbidity and Health Systems: Challenges and Priorities

Abstract Older patients, suffering from numerous diseases and taking multiple medications are the rule rather than the exception in primary care. A manifold of medical conditions are often associated with poor outcomes, and their multiple medications raise additional risks of polypharmacy. Such patients account for most healthcare expenditures. Effective approaches are needed to manage such complex patients in primary care. The paper will discuss different models of care as well as major health care challenges in the management of multimorbidity in primary care with focus on interactions (disease-disease, treatment-treatment, and treatment-disease) extrapolated from (disease specific) guidelines and the feasibility to apply these guidelines for and with patients who have multimorbidity.

Association between marital relationship and multimorbidity in middle-aged adults: a longitudinal study across the US, UK, Europe, and China

BackgroundMarital relationship plays an important role in health and wellbeing. However, how marriage is associated with multimorbidity (the co-occurrence of two or more chronic conditions) has not been comprehensively investigated. We aimed to assess the association between marriage and multimorbidity in middle-aged adults. MethodsWe used nationally representative data on 23641 adults aged 50-60 years who participated in four longitudinal studies in the US, UK, Europe, and China (Health and Retirement Study, English Longitudinal Study on Ageing, Survey of Health, Ageing and Retirement in Europe, and China Health and Retirement Longitudinal Study). Respondents were followed up in 2010-11 (baseline), 2012-13, and 2014-15. We used generalized estimating equations to evaluate the associations between marital status (married/partnered or non-married [separated/devoiced/widowed/never married]), marriage duration and multimorbidity, adjusting for socioeconomic and lifestyle factors. ResultsOver 4-year follow-up, 24% (n=5699) of respondents experienced separation, divorce, widowhood, or never-married status, and approximately 43% (n=10228) of respondents reported multimorbidity. Those who were not married had a higher odds of multimorbidity (age-, sex- and region-adjusted odds ratio 1.19; 95% confidence interval 1.14 to 1.25). Those who had been married for 21-30 years had a lower odds of experiencing multimorbidity than those married for less than 10 years. The associations remained robust after adjusting for socioeconomic and lifestyle factors. ConclusionsMarital relationship (status and length) was associated with multimorbidity in middle-aged adults, highlighting the role of marital relationship in shaping the trajectory of health and wellbeing across the life course. These findings provide insight for the prevention and management of chronic disease and multimorbidity.

Stratifying patients for polypharmacy interventions: The case for a new biomarker?

Stratifying patients for polypharmacy interventions: The case for a new biomarker?

Economic burden of comorbid chronic conditions among survivors of stroke in China: 10-year longitudinal study

BackgroundThe coexistence of chronic diseases among people with stroke is common. However, little is known about the extent of incremental healthcare expenditures associated with having physically and psychologically chronic conditions among stroke survivors.MethodsWe used the nationally representative data from the China Health and Nutrition Survey, including 36,076 participants enrolled as our analytic cohort of ten years of follow-up visits (2006, 2009, 2011, 2015). Chronic conditions include hypertension, diabetes, obesity, and impaired cognitive function. Two-part models were used to estimate the effect of comorbid chronic conditions on total annual healthcare expenditure, out-of-pocket (OOP) healthcare expenditure, and incidence of catastrophic healthcare expenditure (CHE).ResultsAmong survivors of stroke during 2006 to 2015, the prevalence rates of hypertension, diabetes, obesity and impaired cognitive function were 75.5, 9.8, 12.7 and 65.1%, significantly higher than those among adults without stroke history (27.9, 2.7, 10.0 and 41.2%). Having hypertension ($794.5, p = 0.004), diabetes ($3978.5, p < 0.001) were associated with the largest incremental total healthcare expenditures. Stroke survivors with diagnosed hypertension and diabetes had additional 5.7 (p < 0.001) and 10.4 (p < 0.001) percentage point of CHE rate, respectively. Total healthcare expenditures were $2413.0 (P < 0.001) and $5151.7 (P < 0.001) higher among patients with 2, and ≥ 3 chronic conditions, respectively, than those individuals with no chronic conditions.ConclusionsExcess expenditures associated with chronic diseases were substantial among stroke survivors. These results highlight the needs for both prevention and better management of multimorbidity among stroke survivors, which in turn may lower the financial burden of treating these concurrent comorbidities.

The management of multi-morbidity in elderly patients: Ready yet for precision medicine in intensive care?

There is ongoing demographic ageing and increasing longevity of the population, with previously devastating and often-fatal diseases now transformed into chronic conditions. This is turning multi-morbidity into a major challenge in the world of critical care. After many years of research and innovation, mainly in geriatric care, the concept of multi-morbidity now requires fine-tuning to support decision-making for patients along their whole trajectory in healthcare, including in the intensive care unit (ICU). This article will discuss current challenges and present approaches to adapt critical care services to the needs of these patients.

The C3-Cloud Approach to Clinical and Technical Co-production of a Multi-morbidity Integrated Care Information Technology Infrastructure.

Introduction:The collaborative cure and care system (C3-Cloud), is a digital infrastructure offering integrated care capability for management of multi-morbidity. C3-Cloud is deployed in three pilot sites, in the UK, Spain and Sweden, integrating with their health systems. The C3-cloud pilots focus on management of congestive heart failure, diabetes, depression, and renal failure. The automatically generated personalized patient care plan is the concept at the heart of C3-Cloud, which offers an integrated view of the patient’s conditions, measurements, medication and goals. Patients and the various healthcare professionals that constitute the Multi-Disciplinary Team (MDT) supporting the patients, can collaboratively review and edit the plan, further increasing its degree of personalisation. The care plan personalisation process is supported by a Clinical Decision Support (CDS) module, implementing over 500 rules, consolidating and reconciling multiple clinical practice guidelines.Challenge: The technical implementation, clinical practice, and organisational structure go hand in hand and need to be evolved in the context of each other. The system needs to provide the necessary functionality for the pilot sites to deliver the envisioned healthcare service. Furthermore, the system needs to accommodate local organisational aspects such as roles, activities familiar to the patients, as well interoperability to existing and local EHR and GP systems. The organisational structure of pilot sites needs to adapt to effectively deploy and integrate the innovative functionality of the system into daily practice. Additionally, the system and the organisational structure, will need to be able to implement the pathway, customized for each pilot site, which represent best practice guidelines. This interdependency results into weaving of clinical, technical and organisational requirements, which need to be managed carefully. Furthermore, as the development of the integrated care model progresses, requirements evolve based on feedback of the stakeholders.Method: C3-Cloud adopted a through-life co-production approach. From conceptual design to deployment, a well-defined process has allowed the validation and verification of the integrated care system offered, from a number of stakeholder perspectives. Clinical and technical reviewers, as well as potential users, continuously reviewed the validity of the resulting solution. A rigorous requirements management process provided very detailed traceability, amongst local clinical scenarios, clinical practice guidelines, technical requirements, system implementation and testing.Discussion and Conclusions: C3-Cloud provides the care plan as a clinically appraised, integrated means of managing four conditions, each in the context of each other. The C3-Cloud co-production process enabled traceability of any part of the system to its clinical rationale and sufficiency of testing. The process resulted in 60 high level integrated care scenarios, over 80 use cases, over 350 functional and quality requirements, and over 500 rules, criteria and personalized goals, reconciled for the four conditions. The process allowed controlled evolution of the requirements and fine-tuning during deployment.Acknowledgements: C3-Cloud is funded from the EU Horizon 2020 research and innovation, under grant agreement No 6891810. This abstract is based on the work and material of the entire C3-Cloud consortium.

Independent Use of a Home-Based Telemonitoring App by Older Patients With Multimorbidity and Mild Cognitive Impairment: Qualitative Study.

BackgroundThe management of multimorbidity is complex and patients have a high burden of disease. When symptoms of dementia also appear, it becomes even more difficult for patients to cope with their everyday lives and manage their diseases. Home-based telemonitoring may support older patients with multimorbidity and mild cognitive impairment (MCI) in their regular monitoring and self-management. However, to date, there has been no investigation into whether patients with MCI are able to operate a telemonitoring app independently to manage their own diseases. This question has become even more important during the current COVID-19 pandemic to maintain high-quality medical care for this patient group.ObjectiveWe examined the following research questions: (1) How do patients with MCI assess the usability of the telemonitoring app? (2) How do patients with MCI assess the range of functions offered by the telemonitoring app? (3) Was there an additional benefit for the patients with MCI in using the telemonitoring app? (4) Were patients with MCI able to use the telemonitoring app independently and without restrictions? (5) To what extent does previous experience with smartphones, tablets, or computers influence the perceived ease of use of the telemonitoring app?MethodsWe performed a formative evaluation of a telemonitoring app. Therefore, we carried out a qualitative study and conducted guided interviews. All interviews were audio-recorded, transcribed verbatim, and analyzed using the Mayring method of structured content analysis.ResultsTwelve patients (8 women, 4 men) were interviewed; they had an average age of 78.7 years (SD 5.6) and an average Mini-Mental State Examination score of 24.5 (SD 1.6). The interviews lasted between 17 and 75 minutes (mean 41.8 minutes, SD 19.4). Nine patients reported that the telemonitoring app was easy to use. All respondents assessed the range of functions as good or adequate. Desired functionalities mainly included more innovative and varied educational material, better fit of the telemonitoring app for specific needs of patients with MCI, and a more individually tailored content. Ten of the 12 patients stated that the telemonitoring app had an additional benefit for them. Most frequently reported benefits included increased feeling of security, appreciation of regular monitoring of vital parameters, and increased independence due to telemonitoring. Eight patients were able to operate the app independently. Participants found the app easy to use regardless of whether they had prior experience with smartphones, tablets, or computers.ConclusionsThe majority of examined patients with MCI were capable of operating the telemonitoring app independently. Crucial components in attaining independent use were comprehensive personal support from the start of use and appropriate design features. This study provides initial evidence that patients with MCI could increasingly be considered as a relevant user group of telemonitoring apps.

Health Communication and Inter-professional Care in Context of Multimorbidity Management: Assessment of Health Professional Curricular Focus in India

To meet the long term care demands of chronic diseases as well as multimorbidity, healthcare providers from different disciplines need to work collaboratively in practice. This requires healthcare providers to be appropriately trained on delivery of inter-professional care (IPC) and health communication aspects during formative professional years. In this study, we have looked at the prevailing undergraduate and postgraduate healthcare professional curricula to understand the focus on health communication and on IPC for the delivery of multidisciplinary care for multimorbidity management. We observe that while there are exclusive courses on health communication being delivered at different levels, the focus on IPC is still in stages of infancy. The IPC component is just beginning to be woven into the health professional curricula through elements like competency-based curriculum, rotational posting, inter-departmental engagements. At the same time, the need to put curricular attention on multimorbidity is also highlighted here. There remains wider scope for strengthening learning on health communication and IPC among different disciplines within the curricula in the context of multimorbidity. We expect our findings to provide key inputs to academic planners and policy makers towards the introduction of adequate curricular components for addressing multimorbidity along with necessary prescriptions for health communication and IPC in India.

An Electronic Health Record Approach to Understanding Drug to Drug Interactions and Associated Knowledge Gaps in Intergrated Care of Multimorbidity.

Multimorbid patients are prescribed a number of medications in parallel, which may often interact with each other, resulting in adverse effects. However, clinical guidelines on prescription of medications predominantly focus on individual conditions do not consider the guidance in the context of other guidelines, resulting in conflicts. C3-Cloud is an integrated care architecture managing multimorbidity, which amongst others, provides clinical decision support, based on reconciled guidelines, and active monitoring of drug interactions. To identify the severe interactions that resulted from multimorbidity management, in order to reevaluate guidelines as well as to identify knowledge gaps in prescribing practice. Method: Descriptive statistical analysis of interactions identified by the C3-Cloud clinical decision support, collected from the C3-Cloud FHIR repository. As part of a feasibility study, a number of interactions were identified, along with variable practice in how chemicals are represented in the EHR. 191 known severe interactions were identified. The Atorvastatin/Verapamil interaction was the most frequent. The approach has identified a number of interactions where the severity was not available, highlighting the need for further clinical review.

The changing landscape of cardiac rehabilitation; from early mobilisation and reduced mortality to chronic multi-morbidity management

Aim This paper aims to demonstrate how the rationale and delivery of cardiac rehabilitation (CR), in those countries with long term established standards of practice, has changed over the past eight decades. Methods A narrative report based on the evolution of key published guidelines, systematic reviews and medical policies since the 1940s. Results Case reports of the value of exercise in cardiac disease can be dated back to 1772. Formative groundwork for exercise-based CR was published between 1940 and 1970. However, it was not until the late 1980s that a large enough data set of controlled trials was available to show significant reductions in premature all-cause and cardiac mortality. Since the mid 1990s, cardiac mortality has been greatly reduced due to enhanced public health, emergency care and more sensitive diagnostic techniques and aggressive treatments. As a result, there appears to be an associated reduced potency of CR to affect mortality. New rationales for why, how and where CR is delivered have emerged including: adapting to a longer surviving ageing multi-morbid population, where healthcare cost savings and quality of life have become increasingly important. Conclusions In light of these results, an emerging focus for CR, and in some cases “pre-habilitation”, is that of a chronic disability management programme increasingly delivered in community and home settings. Within this delivery model, the use of remote personalised technologies is now emerging, especially with new needs accelerated by the pandemic of COVID-19. IMPLICATIONS FOR REHABILITATION With continued advances in medical science and better long term survival, the nature of cardiac rehabilitation has evolved over the past eight decades. It was originally an exercise-focused intervention on short term recovery and reducing cardiac and all-cause mortality, to now being one part of a multi-factor lifestyle, behavioural, and medical chronic disease management programme. Throughout history, the important influence of psycho-social well-being and human behaviour has, however, always been of key importance to patients. The location of rehabilitation can now be suited to patient need, both medically and socially, where the same components can be delivered in either a traditional outpatient clinic, community settings, at home and more recently all of these being supported or augmented with the advent of mobile technology.

Understanding GPs' clinical reasoning processes involved in managing patients suffering from multimorbidity: A systematic review of qualitative and quantitative research.

BackgroundMost consultations in primary care involve patients suffering from multimorbidity. Nevertheless, few studies exist on the clinical reasoning processes of general practitioners (GPs) during the follow‐up of these patients. The aim of this systematic review is to summarise published evidence on how GPs reason and make decisions when managing patients with multimorbidity in the long term.MethodsA search of the relevant literature from Medline, Embase, PsycINFO, and ERIC databases was conducted in June 2019. The search terms were selected from five domains: primary care, clinical reasoning, chronic disease, multimorbidity, and issues of multimorbidity. Qualitative, quantitative, and mixed‐methods studies published in English and French were included. Quality assessment was performed using the Mixed Methods Appraisal Tool.ResultsA total of 2 165 abstracts and 362 full‐text articles were assessed. Thirty‐two studies met the inclusion criteria. Results showcased that GPs’ clinical reasoning during the long‐term management of multimorbidity is about setting intermediate goals of care in an ongoing process that adapts to the patients’ constant evolution and contributes to preserve their quality of life. In the absence of guidelines adapted to multimorbidity, there is no single correct plan, but competing priorities and unavoidable uncertainties. Thus, GPs have to consider and weigh multiple factors simultaneously. In the context of multimorbidity, GPs describe their reasoning as essentially intuitive and seem to perceive it as less accurate. These clinical reasoning processes are nevertheless more analytical as they might think and rooted in deep knowledge of the individual patient.ConclusionsAlthough the challenges GPs are facing in the long‐term follow‐up of patients suffering from multimorbidity are increasingly known, the literature currently offers limited information about GPs’ clinical reasoning processes at play. GPs tend to underestimate the complexity and richness of their clinical reasoning, which may negatively impact their practice and their teaching.

Estimating and characterizing the burden of multimorbidity in the community: A comprehensive multistep analysis of two large nationwide representative surveys in France.

BackgroundGiven the increasing burden of chronic conditions, multimorbidity is now a priority for healthcare and public health systems worldwide. Appropriate methodological approaches for assessing the phenomenon have not yet been established, resulting in inconsistent and incomplete descriptions. We aimed to estimate and characterize the burden of multimorbidity in the adult population in France in terms of number and type of conditions, type of underlying mechanisms, and analysis of the joint effects for identifying combinations with the most deleterious interaction effects on health status.Methods and findingsWe used a multistep approach to analyze cross-sectional and longitudinal data from 2 large nationwide representative surveys: 2010/2014 waves of the Health, Health Care, and Insurance Survey (ESPS 2010–2014) and Disability Healthcare Household Survey 2008 (HSM 2008), that collected similar data on 61 chronic or recurrent conditions. Adults aged ≥25 years in either ESPS 2010 (14,875) or HSM 2008 (23,348) were considered (participation rates were 65% and 62%, respectively). Longitudinal analyses included 7,438 participants of ESPS 2010 with follow-up for mortality (97%) of whom 3,798 were reinterviewed in 2014 (52%). Mortality, activity limitation, self-reported health, difficulties in activities/instrumental activities of daily living, and Medical Outcomes Study Short-Form 12-Item Health Survey were the health status measures. Multiple regression models were used to estimate the impact of chronic or recurrent conditions and multimorbid associations (dyads, triads, and tetrads) on health status. Etiological pathways explaining associations were investigated, and joint effects and interactions between conditions on health status measures were evaluated using both additive and multiplicative scales.Forty-eight chronic or recurrent conditions had an independent impact on mortality, activity limitations, or perceived heath. Multimorbidity prevalence varied between 30% (1-year time frame) and 39% (lifetime frame), and more markedly according to sex (higher in women), age (with greatest increases in middle-aged), and socioeconomic status (higher in less educated and low-income individuals and manual workers). We identified various multimorbid combinations, mostly involving vasculometabolic and musculoskeletal conditions and mental disorders, which could be explained by direct causation, shared or associated risk factors, or less frequently, confounding or chance. Combinations with the highest health impacts included diseases with complications but also associations of conditions affecting systems involved in locomotion and sensorial functions (impact on activity limitations), and associations including mental disorders (impact on perceived health). The interaction effects of the associated conditions varied on a continuum from subadditive and additive (associations involving cardiometabolic conditions, low back pain, osteoporosis, injury sequelae, depression, and anxiety) to multiplicative and supermultiplicative (associations involving obesity, chronic obstructive pulmonary disease, migraine, and certain osteoarticular pathologies). Study limitations included self-reported information on chronic conditions and the insufficient power of some analyses.ConclusionsMultimorbidity assessments should move beyond simply counting conditions and take into account the variable impacts on health status, etiological pathways, and joint effects of associated conditions. In particular, the multimorbid combinations with substantial health impacts or shared risk factors deserve closer attention. Our findings also suggest that multimorbidity assessment and management may be beneficial already in midlife and probably earlier in disadvantaged groups.

Community assets and multimorbidity: A qualitative scoping study

Little is known of how community assets can play a role in multimorbidity care provision. Using a rapid ethnographic approach, the study explored perceptions of the role of community assets in how multimorbidity is managed within Southwark and Lambeth in Southeast London, England. The scoping work comprised of four micro-studies covering (1) Rapid review of the literature (2) Documentary analysis of publicly available local policy documents (3) Thematic analysis of community stories and (4) Semi-structured stakeholder interviews. The data were analysed using framework thematic analysis. Themes are presented for each of the microstudies. The literature review analysis highlights the role of attitudes and understandings in the management of multiple long-term conditions and the need to move beyond silos in their management. Documentary analysis identifies a resource poor climate, whilst recognising the role of community assets and solution-focussed interventions in the management of multimorbidity. Community patient stories underline the lack of joined up care, and psychosocial issues such as the loss of control and reducing isolation. The stakeholder interview analysis reveals again a sense of disjointed care, the need for holism in the understanding and treatment of multimorbidity, whilst recognising the important role of community-based approaches, beyond the biomedical model. Recommendations stemming from the study’s findings are proposed. Upholding access to and resourcing community assets have key practical importance.

Personalized Multimorbidity Management for Patients with Type 2 Diabetes Using Reinforcement Learning of Electronic Health Records.

BackgroundComorbid chronic conditions are common among people with type 2 diabetes. We developed an artificial intelligence algorithm, based on reinforcement learning (RL), for personalized diabetes and multimorbidity management, with strong potential to improve health outcomes relative to current clinical practice.MethodsWe modeled glycemia, blood pressure, and cardiovascular disease (CVD) risk as health outcomes, using a retrospective cohort of 16,665 patients with type 2 diabetes from New York University Langone Health ambulatory care electronic health records in 2009–2017. We trained an RL prescription algorithm that recommends a treatment regimen optimizing patients’ cumulative health outcomes using their individual characteristics and medical history at each encounter. The RL recommendations were evaluated on an independent subset of patients.ResultsThe single-outcome optimization RL algorithms, RL–glycemia, RL–blood pressure, and RL–CVD, recommended consistent prescriptions as that observed by clinicians in 86.1%, 82.9%, and 98.4% of the encounters, respectively. For patient encounters in which the RL recommendations differed from the clinician prescriptions, significantly fewer encounters showed uncontrolled glycemia (A1c > 8% in 35% of encounters), uncontrolled hypertension (blood pressure > 140 mmHg in 16% of encounters), and high CVD risk (risk > 20% in 25% of encounters) under RL algorithms compared with those observed under clinicians (43%, 27%, and 31% of encounters, respectively; all p < 0.001).ConclusionsA personalized RL prescriptive framework for type 2 diabetes yielded high concordance with clinicians’ prescriptions, and substantial improvements in glycemia, blood pressure, and CVD risk outcomes.Electronic supplementary materialThe online version of this article (10.1007/s40265-020-01435-4) contains supplementary material, which is available to authorized users.

Managing Multimorbidity (Multiple Chronic Diseases) Amid COVID-19 Pandemic: A Community Based Study From Odisha, India.

While most of the studies to date demonstrate the deleterious effect of multiple chronic diseases on COVID-19 risk and outcome, there is sparse information available on the effect of the pandemic on multimorbidity management, with no reports yet from India. We sought to explore the effect of COVID-19 pandemic on routine and emergency care for multimorbidity among community-dwelling adults in Odisha, India. A community-based cross-sectional study was undertaken pandemic lockdown, in Khurda district of Odisha, India. Around 600 individuals having at least one chronic disease residing in rural, urban residential and slums were interviewed using a specifically developed questionnaire MAQ COVID-19. The association of socio-demographic characteristics and multimorbidity with pandemic-related care challenges was examined by multiple logistic regression. Principal Component Analysis was employed to minimize the dimensionality of factors related to multimorbidity care. Multimorbidity was highly prevalent in younger age group (46–60 years) with cardio-metabolic clusters being dominant. Individuals with multimorbidity experienced significantly higher care challenges than those with single condition (AOR = 1.48, 95% CI = 1.01–2.05) with notable disruption in treatment and routine check-up. Most frequently cited concerns were—physician consultation (43%), diagnostic-services (26%), transport (33%), and mobility restrictions (21%). Multivariate analysis revealed older adults living alone in urban residence to have higher challenges than their rural counterparts. Patient activation for self-care, multimorbidity literacy, and technology-enabled tele-consultation could be explored as potential interventions. Future studies should qualitatively explore the challenges of physicians as well as garner an in-depth understanding of multimorbidity management in the vulnerable subgroups.