scholarly journals Characteristics and outcomes of clusters of multimorbid patients in UK general practice

2019 ◽  
Vol 29 (Supplement_4) ◽  
Author(s):  
Y Zhu ◽  
D Edwards ◽  
S Kiddle ◽  
R Payne
Keyword(s):  
Cardiovascular Disease ◽  
General Practice ◽  
Health Services ◽  
Mortality Risk ◽  
Service Use ◽  
Service Utilisation ◽  
Validation Data ◽  
Long Term Conditions ◽  
Co Morbidity

Abstract Background Current clinical specialities, guidelines and quality of care metrics are organised around single diseases and treatments of multiple conditions are rarely coordinated, resulting in insufficient or even conflicting care. This study uses large scale English general practice (GP) records to identify and characterise clusters of patients based on their multimorbidity to allow better design of health services and highlight groups that require additional interventions. Methods This is a retrospective cohort study that includes multimorbid adult patients (N = 113,211), from a random sample of 391,669 English patients with valid GP records in 2012 where 38 long-term conditions were defined. Latent class analysis, stratified by age groups, was used to identify multimorbidity clusters. Class solutions are validated and associations between multimorbidity clusters, patient characteristics, public health service utilisation and mortality are assessed. Results Poor socioeconomic status is associated with clusters with higher service use and mortality risk. Physical-mental health co-morbidity is a major component of multimorbidity across all age strata. The clusters with highest age-stratified mortality risk in under 65 year olds were linked to alcohol and substance misuse, whereas in over 65 year olds they were linked to cardiovascular disease. The largest cluster in the 85+ years strata (58%) has the lowest number of morbidities, a low degree of service use and mortality. Consistency was seen across identification and validation data. Conclusions We find a clear distinction between morbidity clusters, both in the prevalence of long term conditions within them, and in their associations with outcomes (service use and mortality). Specific health services and interventions might be more effective when targeted on the distinct types of multimorbidity we have identified, with a particular focus on the morbidity clusters associated with the worst patient outcomes. Key messages The first study to derive age stratified multimorbidity clusters from a large GP record system, whose patients are representative of the English population. Knowledge about particularly dangerous clusters of multimorbidity, such as those involving alcohol and drug use in 18–64 years old, and cardiovascular disease in those 65 years or older.

scholarly journals Characteristics, service use and mortality of clusters of multimorbid patients in England: a population-based study

2019 ◽  
Author(s):  
Yajing Zhu ◽  
Duncan Edwards ◽  
Jonathan Mant ◽  
Rupert A Payne ◽  
Steven Kiddle
Keyword(s):  
Coronary Heart Disease ◽  
Heart Disease ◽  
Service Use ◽  
Substance Misuse ◽  
Alcohol Misuse ◽  
Psychoactive Substance ◽  
Long Term Conditions ◽  
Co Morbidity ◽  
Multimorbid Patients

AbstractBackgroundMultimorbidity is one of the principal challenges facing health systems worldwide. To help understand the changes to services and policies that are required to deliver better care, we used a novel approach to investigate which diseases co-occur and how combinations are associated with mortality and service use.MethodsLinked primary and secondary care electronic health records contributed by 382 general practices in England to the Clinical Practice Research Datalink (CPRD) were used. The study included a representative set of multimorbid adults (18 years old or more) with two or more long-term conditions (N=113,211). A random set of 80% of the multimorbid patients (N=90,571) were stratified by age and clustered using latent class analysis. Consistency between obtained disease profiles, classification quality and associations with demographic characteristics and primary outcomes (hospitalisation, polypharmacy and mortality) was validated in the remaining 20% of multimorbid patients (N=22,640).FindingsWe identified twenty patient clusters across four age strata. The clusters with the highest mortality comprised psychoactive substance and alcohol misuse (aged 18-64), coronary heart disease, depression and pain (aged 65-84) and coronary heart disease, heart failure and atrial fibrillation (aged 85+). The clusters with the highest service use coincided with those with highest mortality for people aged over 65. For people aged 18-64, the cluster with the highest service use comprised depression, anxiety and pain. The majority of 85+ year olds multimorbid patients belonged to the cluster with the lowest service use and mortality for that age range. Pain featured in thirteen clusters.InterpretationThis work has highlighted patterns of multimorbidity that have implications for health services. These include the importance of psychoactive substance and alcohol misuse in people under the age of 65; of co-morbid depression and coronary heart disease in people aged 65-84, and of cardiovascular disease in people aged 85+.FundingUK Medical Research CouncilResearch in contextEvidence before this studyWe searched PubMed using the keyword list “multimorbidity, co-morbidity, disease patterns, clusters, service use, long-term conditions, chronic conditions” for studies published in English. We also reviewed multiple systematic reviews of multimorbidity patterns, and the policy report of multimorbidity research issued by the Academy of Medical Sciences in 2018.Most studies have focused on older populations (aged 60+) and often used a small list of long-term conditions. Multimorbidity clusters composed of more than two conditions have not been well profiled mostly due to non-representative and small samples. There is substantial heterogeneity in the number of conditions considered (often less than 20) and in the statistical methods. Most studies focused on grouping diseases rather than patients, making it less straightforward to relate patients to outcomes in order to facilitate patient-centred care.Added value of this studyThis study is the first to describe and validate clusters of multimorbid patients across the adult lifecourse using a patient-centred probabilistic clustering approach. This leads to a more nuanced understanding of the relationship between age, multimorbidity and mortality and new insights into the importance of different clusters. For example, contrary to perceived wisdom, we show that the majority of 85+ year old multimorbid patients belong to a cluster with relatively low service use and mortality for that age group. We identify a cluster of younger multimorbid patients with psychoactive substance misuse that have a mortality rate 18 times higher than their non-multimorbid peers.Implications of all the available evidenceWe have validated and added to the list of disease combinations where tailored approaches could be attempted to better manage multimorbid patients and develop effective interventions. For example, the high mortality of younger multimorbid patients with psychoactive substance misuse might be reduced by addressing risk factors (e.g. drug use, smoking, deprivation) which are amenable to intervention.

scholarly journals Are the needs of people with multiple long-term conditions being met? Evidence from the 2018 General Practice Patient Survey

BMJ Open ◽  
2020 ◽  
Vol 10 (11) ◽  
pp. e041569
Author(s):  
Lucina Rolewicz ◽  
Eilís Keeble ◽  
Charlotte Paddison ◽  
Sarah Scobie
Keyword(s):  
General Practice ◽  
Unmet Need ◽  
Patient Survey ◽  
Secondary Outcome ◽  
Community Based ◽  
Long Term Conditions ◽  
Local Services ◽  
Community Based Services ◽  
Practice Patient

ObjectivesTo investigate individual, practice and area level variation in patient-reported unmet need among those with long-term conditions, in the context of general practice (GP) appointments and support from community-based services in England.DesignCross-sectional study using data from 199 150 survey responses.SettingPrimary care and community-based services.ParticipantsRespondents to the 2018 English General Practice Patient Survey with at least one long-term condition.Primary and secondary outcome measuresThe primary outcomes were the levels of unmet need in GP and local services among patients with multiple long-term conditions. Secondary outcomes were the proportion of variation explained by practice and area-level factors.ResultsThere was no relationship between needs being fully met in patients’ last practice appointment and number of long-term conditions once sociodemographic characteristics and health status were taken into account (5+conditions−OR=1.04, 95% CI 0.99 to 1.09), but there was a relationship for having enough support from local services to manage conditions (5+conditions−OR=0.84, 95% CI 0.80 to 0.88). Patients with multimorbidity that were younger, non-white or frail were less likely to have their needs fully met, both in GP and from local services. Differences between practices and local authorities explained minimal variation in unmet need.ConclusionsLevels of unmet need are high, particularly for support from community services to manage multiple conditions. Patients who could be targeted for support include people who feel socially isolated, and those who have difficulties with their day-to-day living. Younger patients and certain ethnic groups with multimorbidity are also more likely to have unmet needs. Increased personalisation and coordination of care among these groups may help in addressing their needs.

Development, implementation and evaluation of nurse-led integrated, person-centred care with long-term conditions

2017 ◽  
Vol 25 (3) ◽  
pp. 186-195 ◽  
Author(s):  
Clare Lynette Harvey ◽  
Jonathan Sibley ◽  
Janine Palmer ◽  
Andrew Phillips ◽  
Eileen Willis ◽  
...  
Keyword(s):  
Health Services ◽  
Chronic Conditions ◽  
Well Being ◽  
Multiple Chronic Conditions ◽  
Long Term Conditions ◽  
Content Type ◽  
Care Services ◽  
Health Strategy ◽  
Global Increase

Purpose The purpose of this paper is to outline a conceptual plan for innovative, integrated care designed for people living with long-term conditions (LTCs). Design/methodology/approach The conceptual plan delivers a partnership between the health system, the person with LTCs (chronic), their family, and the community. The partnership aims to support people at home with access to effective treatment, consistent with the New Zealand Government Health Strategy. This concept of people-owned care is provided by nurses with advanced practice skills, who coordinate care across services, locations and multiple LTCs. Findings With the global increase in numbers of people with multiple chronic conditions, health services are challenged to deliver good outcomes and experience. This model aims to demonstrate the effective use of healthcare resources by supporting people living with a chronic condition, to increase their self-efficacy and resilience in accordance with personal, cultural and social circumstance. The aim is to have a model of care that is replicable and transferable across a range of health services. Social implications People living with chronic conditions can be empowered to manage their health and well-being, whilst having access to nurse-led care appropriate to individual needs. Originality/value Although there are examples of case management and nurse-led coordination, this model is novel in that it combines a liaison nursing role that works in partnership with patients, whilst ensuring that care across a number of primary and secondary care services is truly integrated and not simply interfaced.

Community Mental Health Care for Former Hospital In-Patients: Predicting Costs from Needs and Diagnoses

1995 ◽  
Vol 166 (S27) ◽  
pp. 10-18 ◽  
Author(s):  
Martin Knapp ◽  
Jennifer Beecham ◽  
Andrew Fenyo ◽  
Angela Hallam
Keyword(s):  
Service Use ◽  
Central Government ◽  
Personal Characteristics ◽  
Service Needs ◽  
Service Utilisation ◽  
Community Based ◽  
One Year ◽  
The Uk ◽  
Care Costs

Background. In the UK the replacement of long-term in-patient care with community-based support has been part of central government health policy for many years. One of the challenges of implementing such a policy is the prediction of support and service needs in the community and the associated costs.Method. Using research data from north London analyses were undertaken to examine the associations between service use and costs in the community and the characteristics of hospital in-patients.Results. Although clinical diagnosis was not a useful predictor of either service utilisation or costs, more than a third of the variation in community care costs could be explained by symptoms, behaviour and personal characteristics at least one year earlier.

scholarly journals Comparison of the Impact of “Fast Decline” in Residual Renal Function and “Initial Anuria” on Long-Term Outcomes in Capd Patients

2015 ◽  
Vol 35 (2) ◽  
pp. 172-179 ◽  
Author(s):  
Yi-Hua Lu ◽  
Jyh-Chang Hwang ◽  
Ming-Yan Jiang ◽  
Charn-Ting Wang
Keyword(s):  
Renal Function ◽  
Mortality Risk ◽  
Residual Renal Function ◽  
Long Term Outcomes ◽  
Co Morbidity ◽  
Fast Decline ◽  
Long Term Prognosis ◽  
The Impact ◽  
Regression Tests

BackgroundResidual renal function (RRF) is pivotal to long-term outcomes, while rapid RRF decline (RRFD) is associated with mortality risk for continuous ambulatory peritoneal dialysis (CAPD) patients. This study was conducted to compare the impact of “initial anuria” and rapid RRFD on the long-term prognosis of CAPD patients.MethodAccording to the timing of anuria and the slope of RRFD, a total of 255 incident CAPD patients were divided into 3 groups. For the “anuria” group, anuria was detected from CAPD initiation and persisted for > 6 months ( n = 27). Based on the median of the RRFD slope, the other 228 non-anuric patients were divided into a “slow decliner” group ( n = 114), and a “rapid decliner” group ( n = 114). The maximal observation period was 120 months.ResultsLogistic regression tests indicated that the “anuria” group was associated with previous hemodialysis > 3 months (odds ratio [OR]: 8.52, 95% confidence interval [CI]: 3.12 - 23.28), and female (OR: 0.29, 95% CI: 0.09 - 0.90), while the “fast decliner” group with higher Davies co-morbidity scores (DCS) (OR: 1.52; 95% CI: 1.08 - 2.14), body mass index (BMI) (OR: 1.12; 95% CI: 1.04 - 1.21), and male (OR: 1.12; 95% CI: 1.04 - 1.21). After adjusting for DCS, the “fast decliner” group (hazard ratio [HR]: 0.37; 95% CI: 0.17 - 0.80) showed a better outcome than that of the “anuria” group (reference = 1). Both baseline RRF (β = -0.24; p < 0.001) and DCS (β = -3.76; p < 0.001) showed inverse linear correlations to the slope of RRFD. From the Cox proportional analyses, higher baseline RRF (HR: 0.92; 95% CI: 0.88 - 0.97) and higher slope of RRFD (slower decline in RRF) (HR: 0.90; 95% CI: 0.85 - 0.96) were independent factors for less mortality risk in patients with DCS = 0. However, only a higher slope of RRFD (HR: 0.97; 95% CI: 0.94 - 0.99) was significant for better survival in CAPD patients with DCS > 0.ConclusionCompared to the baseline RRF, CAPD patients with co-morbidities that rapidly deteriorate RRFD are more crucially associated with long-term mortality risk.

scholarly journals Heart Failure and Multimorbidity in Australian General Practice

2017 ◽  
Vol 7 (1) ◽  
pp. 44-49 ◽  
Author(s):  
Clare J. Taylor ◽  
Christopher Harrison ◽  
Helena Britt ◽  
Graeme Miller ◽  
FD Richard Hobbs
Keyword(s):  
Heart Failure ◽  
General Practice ◽  
Chronic Illnesses ◽  
Common Disease ◽  
Ageing Population ◽  
Long Term Conditions ◽  
Australian General Practice ◽  
Current Guidelines ◽  
Active Patients

Background Heart failure (HF) is a serious condition that mostly affects older people. Despite the ageing population experiencing an increased prevalence of many chronic conditions, current guidelines focus on isolated management of HF. Objective To describe the burden of multimorbidity in patients with HF being managed in general practice in Australia. Design Data from the Bettering the Evaluation And Care of Health (BEACH) programme were used to determine (i) the prevalence of HF, (ii) the number of co-existing long-term conditions, and (iii) the most common disease combinations in patients with HF. The study was undertaken over fifteen, 5-week recording periods between November 2012 and March 2016. Results The dataset included a total of 25,790 general practitioner (GP) encounters with patients aged ≥45 years, collected by 1,445 GPs. HF had been diagnosed in 1,119 of these patients, a prevalence of 4.34% (95% confidence interval [CI] 3.99–4.68) among patients at GP encounters, and 2.08% (95% CI 1.87–2.29) when applied to the general Australian population overall. HF rarely occurred in isolation, with 99.1% of patients having at least one and 53.4% having six or more other chronic illnesses. The most common pair of comorbidities among active patients with HF was hypertension and osteoarthritis (43.4%). Conclusion Overall, one in every 20–25 GP encounters with patients aged ≥45 years in Australia is with a patient with HF. Multimorbidity is a typical presentation among this patient group and guidelines for general practice must take this into account.

scholarly journals Making the link: using long-term cancer survival measures linked with acute care data to plan health services.

2018 ◽  
Vol 3 (4) ◽  
Author(s):  
Cameron Wright ◽  
Rachael Moorin
Keyword(s):  
Health Service ◽  
Health Services ◽  
Acute Care ◽  
Service Use ◽  
Cancer Survival ◽  
Service Planning ◽  
Parametric Models ◽  
Expected Number ◽  
Services Research

IntroductionLong-term cancer survival measures have become more important as management has improved outcomes. However, we know some cancer-related acute care use persists into the long-term. This project sought to integrate cancer survival analysis and health services research, validating our modelling retrospectively, for prospective application for health service planning. Objectives and ApproachWe used linked Western Australian cancer registry, mortality and hospitalisation data. Flexible parametric models for first-time invasive cancer diagnoses between 1/1/1997 and 31/12/2006 were used to extract marginal estimates of the cure proportion –that expected not to experience excess mortality from cancer - for those diagnosed in 1999. Fine and Gray competing risks regression was used to estimate the proportion who had died of non-cancer causes. The expected number of individuals diagnosed in 1999 still alive in 2011 was multiplied by the mean expected rate of cancer-related hospitalisations 12 years post-diagnosis (modelled for individuals diagnosed between 1/1/1997 and 31/12/2011). ResultsCure modelling was appropriate for colorectal cancer (CRC) and melanoma. CRC cure proportions were 0.58 for ≤ 50 years at diagnosis, 0.61 for 51 – 70 years, and 0.49 for ≥71 years. For melanoma, corresponding proportions were 0.94, 0.91 and 0.83. The expected number still alive in 2011 was similar to the actual observed in the linked data for the youngest age group, with an over-estimate for older groups. The actual age-standardised, cancer-related hospitalisations in 2011 for those diagnosed with CRC or melanoma in 1999, was within the lower and upper limits of the expected number for all except melanoma diagnosed between 51 and 70 years of age. For this group, observed cancer-related hospitalisations were higher than the expected (355 versus 271 (203 – 341)). Conclusion/ImplicationsCancer registry linked with health service use data can provide useful insights for health service planners. While a decline in cancer-related hospitalisations from diagnosis is expected, this study shows that some demand remains 12 years post-diagnosis. Further refinement of our approach will facilitate its utility in planning cancer-related acute care.

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