Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study
TL;DR: The findings challenge the single-disease framework by which most health care, medical research, and medical education is configured, and a complementary strategy is needed, supporting generalist clinicians to provide personalised, comprehensive continuity of care, especially in socioeconomically deprived areas.
About: This article is published in The Lancet.The article was published on 2012-07-07. It has received 4839 citations till now. The article focuses on the topics: Comorbidity & Health services research.
Citations
More filters
TL;DR: The first World report on ageing and health is released, reviewing current knowledge and gaps and providing a public health framework for action, built around a redefinition of healthy ageing that centres on the notion of functional ability.
1,341 citations
TL;DR: This report discusses how avoidable waste can be considered when research priorities are set and recommends ways to improve the yield from basic research, and the transparency of processes by which funders prioritise important uncertainties should be increased.
1,069 citations
TL;DR: A large and growing body of evidence indicates that experiences of racial discrimination are an important type of psychosocial stressor that can lead to adverse changes in health status and altered behavioral patterns that increase health risks.
Abstract: This article reviews the scientific research that indicates that despite marked declines in public support for negative racial attitudes in the United States, racism, in its multiple forms, remains embedded in American society. The focus of the article is on the review of empirical research that suggests that racism adversely affects the health of nondominant racial populations in multiple ways. First, institutional racism developed policies and procedures that have reduced access to housing, neighborhood and educational quality, employment opportunities, and other desirable resources in society. Second, cultural racism, at the societal and individual level, negatively affects economic status and health by creating a policy environment hostile to egalitarian policies, triggering negative stereotypes and discrimination that are pathogenic and fostering health-damaging psychological responses, such as stereotype threat and internalized racism. Finally, a large and growing body of evidence indicates that experiences of racial discrimination are an important type of psychosocial stressor that can lead to adverse changes in health status and altered behavioral patterns that increase health risks.
862 citations
Cites background from "Epidemiology of multimorbidity and ..."
...The co-occurrence of multiple diseases is commonplace, increase with age, and is evident at younger ages among low-SES and minority populations (Barnett et al., 2012)....
[...]
TL;DR: The concept of microglial priming, and the subsequent exaggerated response of these cells to secondary systemic inflammation, opens the way to treat neurodegenerative diseases by targeting systemic disease or interrupting the signalling pathways that mediate the CNS response to systemic inflammation.
Abstract: Under physiological conditions, the number and function of microglia--the resident macrophages of the CNS--is tightly controlled by the local microenvironment. In response to neurodegeneration and the accumulation of abnormally folded proteins, however, microglia multiply and adopt an activated state--a process referred to as priming. Studies using preclinical animal models have shown that priming of microglia is driven by changes in their microenvironment and the release of molecules that drive their proliferation. Priming makes the microglia susceptible to a secondary inflammatory stimulus, which can then trigger an exaggerated inflammatory response. The secondary stimulus can arise within the CNS, but in elderly individuals, the secondary stimulus most commonly arises from a systemic disease with an inflammatory component. The concept of microglial priming, and the subsequent exaggerated response of these cells to secondary systemic inflammation, opens the way to treat neurodegenerative diseases by targeting systemic disease or interrupting the signalling pathways that mediate the CNS response to systemic inflammation. Both lifestyle changes and pharmacological therapies could, therefore, provide efficient means to slow down or halt neurodegeneration.
805 citations
TL;DR: The limitations of the current evidence base means that further and better designed studies are needed to inform policy, research and clinical practice, with the goal of improving health-related quality of life for patients with multimorbidity.
Abstract: Introduction
Multimorbidity is a major concern in primary care. Nevertheless, evidence of prevalence and patterns of multimorbidity, and their determinants, are scarce. The aim of this study is to systematically review studies of the prevalence, patterns and determinants of multimorbidity in primary care.
Methods
Systematic review of literature published between 1961 and 2013 and indexed in Ovid (CINAHL, PsychINFO, Medline and Embase) and Web of Knowledge. Studies were selected according to eligibility criteria of addressing prevalence, determinants, and patterns of multimorbidity and using a pretested proforma in primary care. The quality and risk of bias were assessed using STROBE criteria. Two researchers assessed the eligibility of studies for inclusion (Kappa = 0.86).
Results
We identified 39 eligible publications describing studies that included a total of 70,057,611 patients in 12 countries. The number of health conditions analysed per study ranged from 5 to 335, with multimorbidity prevalence ranging from 12.9% to 95.1%. All studies observed a significant positive association between multimorbidity and age (odds ratio [OR], 1.26 to 227.46), and lower socioeconomic status (OR, 1.20 to 1.91). Positive associations with female gender and mental disorders were also observed. The most frequent patterns of multimorbidity included osteoarthritis together with cardiovascular and/or metabolic conditions.
Conclusions
Well-established determinants of multimorbidity include age, lower socioeconomic status and gender. The most prevalent conditions shape the patterns of multimorbidity. However, the limitations of the current evidence base means that further and better designed studies are needed to inform policy, research and clinical practice, with the goal of improving health-related quality of life for patients with multimorbidity. Standardization of the definition and assessment of multimorbidity is essential in order to better understand this phenomenon, and is a necessary immediate step.
771 citations
Cites background or methods or result from "Epidemiology of multimorbidity and ..."
...Age was the most frequently studied determinant of multimorbidity [16,18,20,22,25,27,30,32,34,37,41,47,51,52]....
[...]
...Most of these (11 studies) focused on descriptive information pertaining to the frequency of all possible combinations of two conditions [16,18,24,28,38,43,51] and three studies described combinations of two and three conditions [25,45,52]....
[...]
...Prevalence was significantly higher in women in nine studies [16,22,25,27,30,34,37,47,51] and non-significantly higher in three additional studies [18,21,49]....
[...]
...In 25 studies, multimorbidity was defined as the presence of at least 2 chronic diseases in the same person [15,16,18,19,21,22,24,25,27,28, 33,34,35,37,43,44,45,47,48,51,52]; in 5 studies as the presence of at least 3 chronic diseases [39,40,49,50]; in 12 studies by counting the total number of medical conditions and defining groups accordingly Figure 1....
[...]
...versions of the International Classification of Primary Care (ICPC) [22,24,29–30,34–35,38,41,43,45,46–48,51], the International Classification of Diseases (ICD) versions 9 and 10 [25,27,28,32,33,39,40,42–44,49,50,52,53] and Read codes (the clinical coding system used in General Practice in the UK) [16,17,23,26]....
[...]
References
More filters
TL;DR: The means by which primary care improves health have been identified, thus suggesting ways to improve overall health and reduce differences in health across major population subgroups.
Abstract: Evidence of the health-promoting influence of primary care has been accumulating ever since researchers have been able to distinguish primary care from other aspects of the health services delivery system. This evidence shows that primary care helps prevent illness and death, regardless of whether the care is characterized by supply of primary care physicians, a relationship with a source of primary care, or the receipt of important features of primary care. The evidence also shows that primary care (in contrast to specialty care) is associated with a more equitable distribution of health in populations, a finding that holds in both cross-national and within-national studies. The means by which primary care improves health have been identified, thus suggesting ways to improve overall health and reduce differences in health across major population subgroups.
4,011 citations
TL;DR: A Commission on Social Determinants of Health is launching, which will review the evidence, raise societal debate, and recommend policies with the goal of improving health of the world's most vulnerable people.
3,670 citations
TL;DR: Depression produces the greatest decrement in health compared with the chronic diseases angina, arthritis, asthma, and diabetes, and the urgency of addressing depression as a public-health priority is indicated to improve the overall health of populations.
3,122 citations
Journal Article•
TL;DR: In this paper, the authors explored the effect of depression, alone or as a comorbidity, on overall health status and found that depression produces the greatest decrement in health compared with the chronic diseases angina, arthritis, asthma, and diabetes.
2,800 citations
TL;DR: It is suggested that adhering to current CPGs in caring for an older person with several comorbidities may have undesirable effects and could create perverse incentives that emphasize the wrong aspects of care for this population and diminish the quality of their care.
Abstract: ContextClinical practice guidelines (CPGs) have been developed to improve the
quality of health care for many chronic conditions. Pay-for-performance initiatives
assess physician adherence to interventions that may reflect CPG recommendations.ObjectiveTo evaluate the applicability of CPGs to the care of older individuals
with several comorbid diseases.Data SourcesThe National Health Interview Survey and a nationally representative
sample of Medicare beneficiaries (to identify the most prevalent chronic diseases
in this population); the National Guideline Clearinghouse (for locating evidence-based
CPGs for each chronic disease).Study SelectionOf the 15 most common chronic diseases, we selected hypertension, chronic
heart failure, stable angina, atrial fibrillation, hypercholesterolemia, diabetes
mellitus, osteoarthritis, chronic obstructive pulmonary disease, and osteoporosis,
which are usually managed in primary care, choosing CPGs promulgated by national
and international medical organizations for each.Data ExtractionTwo investigators independently assessed whether each CPG addressed
older patients with multiple comorbid diseases, goals of treatment, interactions
between recommendations, burden to patients and caregivers, patient preferences,
life expectancy, and quality of life. Differences were resolved by consensus.
For a hypothetical 79-year-old woman with chronic obstructive pulmonary disease,
type 2 diabetes, osteoporosis, hypertension, and osteoarthritis, we aggregated
the recommendations from the relevant CPGs.Data SynthesisMost CPGs did not modify or discuss the applicability of their recommendations
for older patients with multiple comorbidities. Most also did not comment
on burden, short- and long-term goals, and the quality of the underlying scientific
evidence, nor give guidance for incorporating patient preferences into treatment
plans. If the relevant CPGs were followed, the hypothetical patient would
be prescribed 12 medications (costing her $406 per month) and a complicated
nonpharmacological regimen. Adverse interactions between drugs and diseases
could result.ConclusionsThis review suggests that adhering to current CPGs in caring for an
older person with several comorbidities may have undesirable effects. Basing
standards for quality of care and pay for performance on existing CPGs could
lead to inappropriate judgment of the care provided to older individuals with
complex comorbidities and could create perverse incentives that emphasize
the wrong aspects of care for this population and diminish the quality of
their care. Developing measures of the quality of the care needed by older
patients with complex comorbidities is critical to improving their care.
2,247 citations