Performance of quantitative measures of multimorbidity: a population-based retrospective analysis

Background Multimorbidity measures are useful for resource planning, patient selection and prioritization, and factor adjustment in clinical practice, research, and benchmarking. We aimed to compare the explanatory performance of the adjusted morbidity group (GMA) index in predicting relevant healthcare outcomes with that of other quantitative measures of multimorbidity. Methods The performance of multimorbidity measures was retrospectively assessed on anonymized records of the entire adult population of Catalonia (North-East Spain). Five quantitative measures of multimorbidity were added to a baseline model based on age, gender, and socioeconomic status: the Charlson index score, the count of chronic diseases according to three different proposals (i.e., the QOF, HCUP, and Karolinska institute), and the multimorbidity index score of the GMA tool. Outcomes included all-cause death, total and non-scheduled hospitalization, primary care and ER visits, medication use, admission to a skilled nursing facility for intermediate care, and high expenditure (time frame 2017). The analysis was performed on 10 subpopulations: all adults (i.e., aged > 17 years), people aged > 64 years, people aged > 64 years and institutionalized in a nursing home for long-term care, and people with specific diagnoses (e.g., ischemic heart disease, cirrhosis, dementia, diabetes mellitus, heart failure, chronic kidney disease, and chronic obstructive pulmonary disease). The explanatory performance was assessed using the area under the receiving operating curves (AUC-ROC) (main analysis) and three additional statistics (secondary analysis). Results The adult population included 6,224,316 individuals. The addition of any of the multimorbidity measures to the baseline model increased the explanatory performance for all outcomes and subpopulations. All measurements performed better in the general adult population. The GMA index had higher performance and consistency across subpopulations than the rest of multimorbidity measures. The Charlson index stood out on explaining mortality, whereas measures based on exhaustive definitions of chronic diagnostic (e.g., HCUP and GMA) performed better than those using predefined lists of diagnostics (e.g., QOF or the Karolinska proposal). Conclusions The addition of multimorbidity measures to models for explaining healthcare outcomes increase the performance. The GMA index has high performance in explaining relevant healthcare outcomes and may be useful for clinical practice, resource planning, and public health research.

All-cause mortality and cardiovascular death in 52091 patients with hypertrophic cardiomyopathy. A nationwide cohort study

Background Patients with hypertrophic cardiomyopathy (HCM) have high risk of death related to cardiovascular (CV) death. Improvements in risk stratification are needed to help identify those HCM patients at higher risk of all-cause death and cardiovascular death. Methods This French longitudinal cohort study from the database covering hospital care from 2010 to 2019 analyzed adultshospitalized with isolated HCM. The overall sample of 52,091 patients was randomly partitioned into derivation (n=26,067) and validation (n=26,024) populations. A logistic regression model was used to construct HCM death and CV-death scores in the derivation sample, which were compared to the Charlson index, Frailty index and CHA2DS2VASc scores using c-indexes and calibration analysis. Results In 52,091 patients with isolated HCM, 12,676 (24.0%) died during follow-up of 3.0±2.8 years (median 2.3, interquartile range 0.4–5.0). Rate of all-cause death was 8.10%/year (7.96–8.24) and was 2.76%/year (2.68–2.84) for CV death.Independent predictors of CV death in HCM were older age, diabetes mellitus, heart failure, history of pulmonary edema, atrial fibrillation, ventricular tachycardia or fibrillation, ischemic stroke, while smoking and poor nutrition were associated with better survival (all p<0.05). In addition to these, male sex, vascular disease, alcohol related diagnoses, kidney disease, lung disease, liver disease anemia and cancer were independent predictors of all-cause death. In the derivation cohort, c-indexes for the HCM death score were 0.720 (0.713–0.727) for all-cause death and 0.695 (0.685–0.705) for CV death. For the HCM CV-death score, c-indexes were 0.679 (0.671–0.686) for all-cause death and 0.723 (0.712–0.733) for CV death. Performances were very similar in the validation cohort. Both scores had good calibrations. Charlson and Frailty indexes however had a better clinical usefulness than the HCM death score and HCM CV-death scores for predicting all-cause death. Decision curve analysis for CV death demonstrated that the HCM CV-death score had the best clinical usefulness of all the tested risk scores. Conclusion HCM patients have a high risk of all-cause and CV mortality. Independent predictors of CV-mortality in HCM were used to derive and validate a simple risk prediction model (French HCM CV-mortality score) which performed better than clinical scores, Charlson Index and Frailty Index; showing the best clinical usefulness, with good calibration. FUNDunding Acknowledgement Type of funding sources: None.

Effect of a geriatric management unit on the outcomes of hospitalized older adults with cancer in Mexico.

12039 Background: Geriatric assessments and interventions improve the outcomes of hospitalized older adults with cancer, but their implementation in developing countries is limited. We studied the effect of a specialized geriatrician-led inpatient geriatric management unit compared with a conventional internal medicine ward on the outcomes of hospitalized Mexican older adults with cancer. Methods: This retrospective study included patients aged ≥65 with solid tumors who had a cancer-related hospitalization at a public academic center in Mexico City between March 2015 and October 2018. Patients hospitalized in the geriatric management unit (cases) were paired in a 1:2 fashion with those in internal medicine wards (controls). Pairing was done by age (+/- 5 years), tumor type, and admission date (+/- 3 months). We studied the effect of being hospitalized in the geriatric management unit on length of stay (LOS), incidence of delirium, hospital-acquired complications, and in-hospital mortality. Multivariate logistic regression models for each outcome were created using variables which were significant on univariate analysis. Results: 300 patients (100 cases, 200 controls, median age 75) were included. The most common tumors were gastrointestinal (GI) (53%) and genitourinary (25%). Both groups were comparable regarding baseline comorbidities (Charlson index 8.5 vs. 7.7, p = 0.99) and illness severity at admission (NEWS2 score 2.6 vs. 2.3, p = 0.82). No difference in median LOS was found between cases and controls (9.1 vs. 9.5 days, p = 0.34). Diagnosis of a GI tumor (OR 3.4, 95% CI 1.3-5.5), hospital-acquired complications (OR 4.9, 95% CI 2.5-7.3), and delirium (OR 5.5, 95% CI 2.3-8.7) were associated with longer LOS. 14% of patients in both groups had delirium. Hospitalization in the geriatric management unit reduced the risk of delirium (OR 0.35, 95% CI 0.1-0.9), while a higher Charlson index (OR 1.2, 95% CI 1.0-1.4), NEWS2 score (OR 1.2, 95% CI 1.1-1.4), and hospital-acquired complications (OR 7.3, 95% CI 2.9-18.5) increased it. 34% of patients developed hospital-acquired complications. Diagnosis of a GI tumor (OR 1.9, 95% CI 1.1-3.3) and higher NEWS2 score (OR 1.2, 95% CI 1.1-1.4) increased the risk of hospital-acquired complications. No differences in in-hospital mortality were seen between cases and controls (12% vs. 10%, p = 0.59). A higher NEWS2 score at admission (OR 1.4, 95% CI 1.2-1.7) and delirium (OR 10.7, 95% CI 3.2-36.3) increased the risk of death. Conclusions: Among older Mexican adults hospitalized for a cancer-related diagnosis, receiving care in a geriatric management unit led to a significant decrease in the risk of delirium. No improvements were seen in LOS, complications, or in-hospital mortality, which were associated with tumor and patient-related characteristics. Geriatric co-management can lead to improved geriatric outcomes in developing countries with limited resources.

AB0759 INDEX OF COMORBIDITY IN PATIENTS WITH LOBULAR PANNICULITIS-LIPODERMATOSCLEROSIS

Background:Early diagnosis of comorbid burden and treatment of rheumatological patients, especially panniculitis (Pn), is a complex problem, the solution of which lies in an interdisciplinary approach and the development of a general algorithm for managing patients.Objectives:To study the structure and frequency of comorbid conditions in patients with Pn-lipodermatosclerosis (LDS).Methods:We examined 53 patients (3 men and 50 women aged 18 to 80) with verified LDS, who were observed at the V.A. Nasonova Research Institute of Rheumatology for ten years on average. The duration of the disease varied from 2 weeks to 20 years. Clinical, laboratory and instrumental examination of patients was carried out twice a year. Clinical examination was carried out to determine localization, prevalence, color and number of the affected areas of skin and subcutaneous fat (SCF), as well as pain intensity according to the Visual Analogue Scale (VAS). Laboratory and instrumental research included standard blood and urine tests, as well as computed tomography of the chest and Doppler ultrasound of the lower extremities. To assess the relationship between the presence of comorbid pathology and the course of LDS the patients were analyzed with the CIRS and Charlson indices.Results:Most patients were overweigh women (60.3%) with average weight of 91.5±21.8 kg. Based on the duration of the disease we identified the main variants of the course of the disease: acute (up to 3 months), subacute (from 3 to 6 months), and chronic (more than 6 months). Skin lesions were associated with polyarthralgias (n=18) and/or myalgias (n=12), mainly in the area of the affected limb. In 16 patients an increase in the erythrocyte sedimentation rate was recorded on average up to 23.8 ±7.8 mm/h. The level of C-reactive protein (CRP) was more than 3 times higher than normal in 7 patients, 4 of them had an acute course of LDS. In the study group 17 patients did not have comorbid diseases, 64.7% of them were under 50 years old with an acute course of LDS (p=0.02). Concomitant pathology was detected in 68% of patients mainly with chronic LDS. In 67.9% of cases it was presented by chronic venous insufficiency (CVI), in 60.3% – by exogenous constitutional obesity, in 45.2% – by rheumatic diseases (75% of these patients had osteoarthritis, 17% – rheumatoid arthritis, 8% – antiphospholipid syndrome) and in 39.6% – arterial hypertension. Most patients had one concomitant disease, almost a fifth of patients had two concomitant diseases. The proportion of patients with three comorbid diseases was 11.1%, four comorbid diseases – 8.3% and five comorbid diseases – 5.5%. When assessing the Charlson index, 10-year survival rates over 90% (index values from 0 to 2 points) were registered in 66% of patients, from 53 to 77% (index values of 3-4) – in 26.4% and less than 21% (≥5 points) – in 7.5%. The comorbidity index correlated with the age of patients (r = 0.8; p<0.05). There was no correlation between the Charlson index and the duration of LDS (r=0.3; p=0.2). In patients older than 61 one or more comorbid conditions were recorded. The CIRS index for this group averaged 4.2 ± 0.3 points (range 0-10), in most patients (45.2%) the CIRS index did not exceed 5 points. An analysis of the relationship between the Charlson and the CIRS scales confirmed their significant correlation at the level of r=0.5, p=0.0000001.Conclusion:In patients with LDS a high incidence of comorbid pathology was detected. The treatment of this variant of panniculitis requires an interdisciplinary approach and interaction between doctors of different specialties.Disclosure of Interests:None declared

AB0865-HPR FREQUENCY OF DEPRESSION IN SYSTEMIC LUPUS ERYTHEMATOSUS

Objectives:Cross-sectional observational study of a series of SLE patients selected from the Rheumatology consultations.Methods:age ≥18 years with SLE (ACR 1997 criteria) capable of understanding and willing to take the questionnaires. Protocol: All patients with SLE undergoing follow-up in the rheumatology clinic are recorded in a database. A telephone call was made to all the patients included in the database and those patients who responded to the call and gave their verbal consent for the collection of data from their clinical history and completed the Goldberg questionnaire were finally included. The nurse was in charge of explaining the questionnaire to the patients. Variables: the main outcome variable was depression assessed by Goldberg (≥2 depression) and other variables were: previous diagnosis of depression, Charlson index, polypharmacy, psychiatric medication, referral to mental health or primary care, SLEDAI and SLICC. Descriptive, bivariate statistical analysis and multivariate logistic regression analysis (VD: Goldberg depression).Results:89 patients with SLE were included (95.5% women, mean age 49.44 ± 13.2 years and 18.28 ± 9.19 years of disease). The mean (SD) of the Goldberg scale in all the patients was 3.2 ± 2.9 and a total of 45 patients (50.4%) met criteria of depression according to Goldberg’s screening, of which 19 (21.3%) patients had a previous diagnosis of depression. Only 9 patients (10.1%) had had a mental health follow-up and 22 patients (24.7%) were being followed by the family doctor. A total of 87 patients (97.8%) presented polypharmacy: severe polypharmacy 59 (66.3%) and 33 (37.1%) psychiatric medication. The most used psychiatric medication was: 7 (7.8%) bromazepam, 6 (6.7%) citalopram, 5 (5.6%) diazepam. Regarding comorbidities, the Charlson index was 1.82 ± 1.21, also highlighting that 34 (27%) of the sample had Sjögren syndrome. In the multivariate analysis, polypharmacy (OR, 1.8 [95% CI, 1.0-3.1]) and Sjogren’s syndrome (OR, 3.8 [95% CI, 1.0-10.7]) were independently associated with depression by Goldberg.Conclusion:Depression is underdiagnosed and undertreated in patients with SLE. Depression is associated with polypharmacy and the perception of patients with SLE of being ill. It is important to correctly treat depression in the context of SLE comorbidity due to its great impact on quality of life.Disclosure of Interests:None declared

Analysis of the structure and severity of comorbid pathology in patients with arterial hypertension

The purpose of the research is to study the structure and severity of comorbid pathology in hospitalized patients with arterial hypertension. Material and methods. The study included 140 adult patients (29% men and 71% women) with arterial hypertension and comorbidity receiving therapy in the cardiology department. The average age of the patients was 64.3 ± 12.0 years. The Charlson index was used to assess comorbidity. Results. The average Charlson index in our study was 3.97 ± 2.0 points. Moderate and severe comorbidity was observed in 77.6% of patients with arterial hypertension. When analyzing the frequency of concomitant pathology, one disease was detected in 7% of the examined, two in 28%, three in 14%, four in 23%, five or more in 28%. The structure of concomitant pathology is represented mainly by chronic cerebral ischemia (26.3%), rhythm and conduction disturbances (20%), diseases of the bronchopulmonary (14.8%) and digestive (12.7%) systems. Analysis of risk factors for comorbidity revealed heredity aggravated by cardiovascular diseases in 33.3% of patients with arterial hypertension, smoking in 7.3%, overweight in 27%, obesity in 62%, and abdominal obesity in 87%. Obesity was not diagnosed in all men and 85.4% of women, which indicates that this risk factor for comorbidity was not taken into account. Conclusion. The introduction into the practice of managing patients with arterial hypertension and comorbidity of scoring the presence of concomitant diseases by calculating the Charlson comorbidity index will increase the accuracy of assessing the prediction of their ten-year survival. Identifying and correcting the main risk factors for comorbidity and concomitant pathology in patients with arterial hypertension can reduce disability and mortality.

MO910CHANGE IN BODY COMPOSITION MEASURED BY BIOIMPEDANCE SPECTROSCOPY AFTER COVID19 LOCKDOWN IN HAEMODIALYSIS PATIENTS

Background and Aims Changes on body composition have an impact on the survival of haemodialysis (HD) patients. The aim of the study was to determine the impact of the reduction of physical activity due to COVID19 lockdown on body composition in HD patients. Method Retrospective and observational study including 149 HD patients. Nutritional and Bioimpedance spectroscopy (BIS) data were recorded before and after COVID19 lockdown (mean of 148 ± 20 days between determinations). Results Over the 49 days of COVID19 lockdown, we observed a decrease in normohydrated weight (NHW) of 1.01 ± 3.59 kg mainly secondary to a reduction on total body water (TBW) 0.95 ± 3.78 L (extracellular water 0.45 ± 1.58 L and intracellular water 0.41 ± 2.36 L). There was also a small loss on lean tissue index (LTI) of 0.28 ± 2.42 kg/m2, with an increase of fat tissue index (FTI) 0f 0.02 ± 2.82 kg/m2. Twenty-three patients presented COVID19 infection, of which 21 required admission (median of 10 [4-16] days). Patients who presented COVID19 were older (70.7 ± 12.0 vs 64.9 ± 16.6 years, NS) with higher Charlson index (7.48 ± 2.77 vs 6.33 ± 2.65, p = 0.07). Patients with COVID19 infection presented a greater loss on LTI (-1.18 ± 3.15 bs -0.16 ± 2.30 kg/m2; p = 0.22), FTI (-0.41 ± 3.38 vs 0.06 ± 2.74 kg/m2; p = 0.54); BMI (-1.49 ± 2.14 vs -0.25 ± 0.96 kg/m2; p = &lt; 0.01) and NHW (-4.00 ± 6.33 vs -0.62 ± 2.90 kg; p = &lt; 0.01) compared to patients without COVID19 infection. The length of hospitalization was associated with greater loss of BMI and NHW, resulting, therefore, in overhydration. There also had lower serum phosphorus (3.6 ± 0.8 vs 5.2 ± 0.8 mg/dl; p = 0.01) and serum albumin (3.5 ± 0.4 vs 4.0 ± 0.1 g/dl; p = 0.01). Seven patients died during hospitalization. Deceased patients were older (78.4 ± 6.6 vs 67.4 ± 12.4 years; p = 0.01), presented higher comorbidity (estimated by Charlson index 10.0 [8.0-11.0] vs 6.5 [4.3-8.0]; p = 0.02) and were more overhydrated (3.4 ± 3.6 vs 1.9 ± 1.9; p = 0.34). Although not statistically different, they had lower LTI (10.4 ± 2.1 vs 12.0 ± 3.4 kg/m2; p = 0.18) and lower serum albumin (3.4 ± 0.6 vs 3.9 ± 0.4 g/dl; p = 0.08) compared to survivors. Patients who survived COVID19 infection had longer hospitalization (57% were discharged between twelfth and forty third day; mean hospitalization 14.6 ± 11.5 days). Deceased patients died within the first 12 days of hospitalization (6.8 ± 4.1 days). Conclusion COVID19 lockdown induced a weight reduction on HD patients due to decrease in total body water. COVID19 infection increased this reduction, inducing greater loss on lean and fat tissue composition. Moreover, COVID19 impact on body composition was magnified with the length of hospitalization.

Prediction of Other-Cause Mortality in Older Patients with Breast Cancer Using Comorbidity

Background: Individualized treatment in older patients with breast cancer can be improved by including comorbidity and other-cause mortality in prediction tools, as the other-cause mortality risk strongly increases with age. However, no optimal comorbidity score is established for this purpose. Therefore, this study aimed to compare the predictive value of the Charlson comorbidity index for other-cause mortality with the use of a simple comorbidity count and to assess the impact of frequently occurring comorbidities. Methods: Surgically treated patients with stages I-III breast cancer aged ≥70 years diagnosed between 2003 and 2009 were selected from the Netherlands Cancer Registry. Competing risk analysis was performed to associate 5-year other-cause mortality with the Charlson index, comorbidity count, and specific comorbidities. Discrimination and calibration were assessed. Results: Overall, 7511 patients were included. Twenty-nine percent had no comorbidities, and 59% had a Charlson score of 0. After five years, in 1974, patients had died (26%), of which 1450 patients without a distant recurrence (19%). Besides comorbidities included in the Charlson index, the psychiatric disease was strongly associated with other-cause mortality (sHR 2.44 (95%-CI 1.70–3.50)). The c-statistics of the Charlson index and comorbidity count were similar (0.65 (95%-CI 0.64–0.65) and 0.64 (95%-CI 0.64–0.65)). Conclusions: The predictive value of the Charlson index for 5-year other-cause mortality was similar to using comorbidity count. As it is easier to use in clinical practice, our findings indicate that comorbidity count can aid in improving individualizing treatment in older patients with breast cancer. Future studies should elicit whether geriatric parameters could improve prediction.

Peculiarities of the postoperative period and postoperative consequences of left hemicolectomy in patients with obesity

Annotation. Obesity is considered a risk factor for postoperative complications and postoperative mortality. The aim of the study was to assess the impact of obesity on the postoperative period and the level of postoperative mortality after left hemicolectomy. A retrospective analysis of the medical records of 217 patients who underwent left hemicolectomy for colon tumors was performed. Assessment of comorbid conditions was performed using the Charlson index. Postoperative complications were assessed according to the Clavien-Dindo classification. The calculation of postoperative survival was performed by the Kaplan-Mayer method. Database formation and statistical analysis were performed using Microsoft Excel and STATISTICA 10.0. It was determined that the mean values of the Charlson index did not differ significantly between the two groups (6,31 ± 2,07 and 6,33 ± 2,08 respectively), but there was a significantly higher level of endocrine diseases in the group of obese patients. Non-disseminated (I-II) stages of the tumor process predominated in patients of both groups (60% and 57.5%, respectively). Among non-obese patients n = 107 (51.8%) patients had an uncomplicated postoperative period and n = 59 (28.5%) patients had mild complications that were not associated with the surgical site, but were associated with concomitant chronic pathology of other organs and systems, and did not require any invasive interventions. In contrast, among obese patients n = 6 (60%) patients had severe early postoperative complications requiring surgery, and n = 2 (20%) patients underwent relaparotomy. The rate of early postoperative mortality differed significantly between the two groups and was significantly higher among obese patients (40% vs 6.8% among non-obese patients). This study showed a significantly higher percentage of postoperative mortality and severity of postoperative complications in the group of obese patients. The prospect of further research is to study and analyze the course of the postoperative period in obese patients undergoing extended, multi-visceral and multi-stage surgery for cancer of the left half of the colon.