Morbidity severity classifying routine consultations from English and Dutch general practice indicated physical health status

OBJECTIVE: To investigate the construct validity of morbidity severity scales based on routine consultation data by studying their associations with sociodemographic factors and physical health. STUDY DESIGN AND SETTING: Study participants were 11,232 English adults aged 50 years and over and 9,664 Dutch adults aged 18 years and over, and their consulting morbidity data in a 12-month period were linked to their physical health data. Consulters with any of 115 morbidities classified on four ordinal scales of severity ("chronicity," "time course," "health care use," and "patient impact") were compared to all other consulters. RESULTS: As hypothesized, in both countries, morbidity severity was associated with older age, female gender, more deprivation (all comparisons P< or =0.05), and poor physical health (all trends P<0.001). The estimated strengths of association of poor physical health with the highest severity category expressed as odds ratios, for each of the four scales, were 5.4 for life-threatening on the "chronicity" scale, 1.8 for time course, 2.8 for high health care use, and 3.7 for high patient impact. CONCLUSIONS: Four scales of morbidity severity have been validated in English and Dutch settings, and they offer the potential to use simple routine consultation data as an indicator of physical health status in populations from general practice.     

Does age modify the relationship between morbidity severity and physical health in English and Dutch family practice populations?

Purpose  To investigate the co-influences of age and morbidity severity on physical health in adult family practice populations. Methods  Morbidity data in a 12-month period for 7,833 older English consulters aged 50 years and over and 6,846 Dutch consulters aged 18 years and over was linked to their physical health status obtained from cross-sectional health surveys. Individual patients were categorised using 78 consulting morbidities classified by a chronicity measure (acute, acute-on-chronic and chronic) into an ordinal scale of morbidity severity ranging from single to multiple chronicity groups. Associations between morbidity severity, age and SF-12 Physical Component Summary (PCS) score were assessed using linear regression methods. Results  Increased age and higher morbidity severity were significantly associated with poorer physical health. Of the explained total variance in adjusted PCS scores, an estimated 43% was attributed to increasing age, 40% to morbidity severity and 17% to deprivation for English consulters; the figures were 21, 42 and 31%, respectively for Dutch consulters. The largest differences in PCS scores between severity categories were observed in the younger age groups. Conclusions  Morbidity severity and age mainly act separately in adversely influencing physical health. In ageing populations who will experience higher multimorbidity, this study underlines the importance that health care and public health will need to address morbidity severity and ageing as related but distinct issues.     

Distinct trajectories of multimorbidity in primary care were identified using latent class growth analysis

ObjectivesTo investigate the use of latent class growth analysis (LCGA) in understanding onset and changes in multimorbidity over time in older adults.Study Design and SettingThis study used primary care consultations for 42 consensus-defined chronic morbidities over 3 years (2003–2005) by 24,615 people aged >50 years at 10 UK general practices, which contribute to the Consultations in Primary Care Archive database. Distinct groups of people who had similar progression of multimorbidity over time were identified using LCGA. These derived trajectories were tested in another primary care consultation data set with linked self-reported health status.ResultsFive clusters of people representing different trajectories were identified: those who had no recorded chronic problems (40%), those who developed a first chronic morbidity over 3 years (10%), a developing multimorbidity group (37%), a group with increasing number of chronic morbidities (12%), and a multi-chronic group with many chronic morbidities (1%). These trajectories were also identified using another consultation database and associated with self-reported physical and mental health.ConclusionThere are distinct trajectories in the development of multimorbidity in primary care populations, which are associated with poor health. Future research needs to incorporate such trajectories when assessing progression of disease and deterioration of health.     

Relationship Between Multimorbidity and Health-Related Quality of Life of Patients in Primary Care

Previous studies about the association of multimorbidity and the health-related quality of life (HRQOL) in primary-care patients are limited because of their reliance on simple counts of diseases from a limited list of diseases and their failure to assess the severity of disease. We evaluated the association while taking into account the severity of the medical conditions based on the Cumulative Illness Rating Scale (CIRS) score, and controlling for potential confounders (age, sex, household income, education, self-perception of economic status, number of people living in the same dwelling, and perceived social support). We randomly selected 238 patients to construct quintiles of increasing multimorbidity (CIRS). Patients completed the 36-item Medical Outcomes study questionnaire (SF-36) to evaluate their HRQOL. Applying bivariate and multivariate linear regression analyses, we used the CIRS as either a continuous or a categorical (quintiles) variable. Use of the CIRS revealed a stronger association of HRQOL with multimorbidity than using a simple count of chronic conditions. Physical more than mental health deteriorated with increasing multimorbidity. Perceived social support and self-perception of economic status were significantly related to all scales of the SF-36 (p < 0.05). Increased multimorbidity adversely affected HRQOL in primary-care adult patients, even when confounding variables were controlled for.     

Trends in morbidity and general practitioners' workload for middle-aged and elderly people from 1956 to 1982

This paper presents analysis of the National Morbidity Surveys carried out in 1956, 1972 and 1982. Over this period an increasing proportion of middle-aged and elderly patients consulted their general practitioners (GPs) and the average patient consulted for more illnesses. This rise in reported morbidity, particularly for circulatory and musculo-skeletal illnesses, occurred during a period of decline in the mortality rate, which suggests that the latter is a poor indicator of population health. The sharp reduction in the consultation rate between 1956 and 1972 suggests that GPs were limiting their role to primary assessment. However, despite a resurgence in the total number of consultations by 1982, the rapid increase in morbidity between 1972 and 1982 further eroded the levels of consultation per episode of illness. Given that the age-structure of the elderly population is gradually shifting upwards and that each generation reports more illness than its predecessor, GPs can expect to face increasing levels of demand for services from elderly patients.     

Previous consultation and self reported health status as predictors of future demand for primary care

STUDY OBJECTIVE: There has been little prospective investigation of what predicts general practice consultation. The objective of this study was to investigate the extent to which previous primary care consultation and self reported health status are predictors of future primary care consultation. DESIGN: Population based cohort study in two phases. Firstly, a baseline survey (1995/96) to identify the cohort and to obtain self reported health status using the UK census limiting long term illness (LLI) question and the Short Form-36 (SF-36) health profile. Secondly, analysis of general practice medical records for two years (1994/1995) before the survey and for two years (1997/1998) after the survey. Analysis was performed on: (a) all contacts coded by the GP, (b) the subgroup of contacts given a diagnostic morbidity code by the GP. SETTING: One general practice in North Staffordshire, UK. PARTICIPANTS: 738 survey respondents who had consented to viewing of medical records including all those who reported LLI together with an age-gender matched control group of those who reported no LLI. MAIN RESULTS: High frequency consulters in 1994/95 were more likely than non-consulters or average consulters in that year to be high consulters in 1997/98 (odds ratio 5.6, 95% confidence interval 3.82 to 8.25, for all contacts; 4.4 for diagnostic coded consultations). Self reported role disability and physical limitation from the SF-36 at baseline increased the probability of being a future high consulter but the effects were weaker than for previous consultation. Previous consultation within a diagnostic group was the main predictor for future consultation within that group with weaker but significant prediction by self reported health status. CONCLUSIONS: Reliable morbidity coding in general practice provides the best available basis for predicting future demand in primary care. Self reported health status survey instruments add to this information but on their own are weaker predictors of future consultation.     

Prevalence,Correlates, and Outcomes of Multimorbidity Among Patients Attending Primary Care in Odisha,India

PURPOSE

Little information is available on multimorbidity in primary care in India. Because primary care is the first contact of health care for most of the population and important for coordinating chronic care, we wanted to examine the prevalence and correlates of multimorbidity in India and its association with health care utilization.

METHODS

Using a structured multimorbidity assessment protocol, we conducted a cross-sectional study, collecting information on 22 self-reported chronic conditions in a representative sample of 1,649 adult primary care patients in Odisha, India.

RESULTS

The overall age- and sex-adjusted prevalence of multimorbidity was 28.3% (95% CI, 24.3–28.6) ranging from 5.8% in patients aged 18 to 29 years to 45% in those aged older than 70 years. Older age, female sex, higher education, and high income were associated with significantly higher odds of multimorbidity. After adjusting for age, sex, socioeconomic status (SES), education, and ethnicity, the addition of each chronic condition, as well as consultation at private hospitals, was associated with significant increase in the number of medicines intake per person per day. Increasing age and higher education status significantly raised the number of hospital visits per person per year for patients with multiple chronic conditions.

CONCLUSION

Our findings of higher prevalence of multimorbidity and hospitalizations in higher SES individuals contrast with findings in Western countries, where lower SES is associated with a greater morbidity burden.     

Associations among family support, family stress, and personal functional health status

The self-reported family support and stress of 249 ambulatory adult patients, aged 18-49 years, were studied relative to their self-reported functional health. Support from family members was found to be related positively with emotional function. Stress from family members was associated negatively with symptom status, physical function, and emotional function. Patients' severity of illness was related negatively to their symptom status, physical function, and social function, but not to their emotional function. During the study a new self-report instrument, the Duke Social Support and Stress Scale (DUSOCS), was developed to measure family and non-family support and stress. Also, a new chart audit methodology, the Duke Severity of Illness Scale (DUSOI), was designed to assess severity in the ambulatory setting. Reliability and validity of the DUSOCS and the DUSOI were supported. The importance of the patient's perception of health and its family determinants is emphasized.     

Outpatient consultations from a family practice residency program: nine years' experience

Previous reports of consultation rates from family practice physicians have included small sample sizes and have suggested higher rates in residency training programs. This report summarizes 9 years of data involving 161 family practice physicians in a residency training program and shows an overall rate of 1.4 percent for outpatient consultations. Otolaryngology, orthopedics, obstetrics/gynecology, and general surgery were the most frequent disciplines consulted. These data are helpful in designing health care systems that include family practice residency programs.     

Inequality in health and health service use for mothers of young children in south west England. Survey Team of the Avon Longitudinal Study of Pregnancy and Childhood Team.

OBJECTIVE: To establish the degree of association between relative deprivation and any variation in condition specific morbidity and in consultations with general practitioners for mothers of young children. STUDY DESIGN: Condition specific morbidity and general practitioner consultation (GP) rates were recorded by means of self reports on a postal questionnaire. Subjects were asked to record whether they had suffered from any of 16 common conditions and, if so, whether they had consulted the GP. Relative deprivation was measured using indicators such as home ownership, overcrowded living conditions, car ownership, and partners' employment status. Information was also collected about the women's own employment status, their ages, and parity. SETTING: The three district health authorities of Bristol. All women expecting a baby between April 1991 and December 1992 were invited to participate. SUBJECTS: Altogether 11040 mothers who completed questionnaires about their own health and well being at 8 months postpartum as part of the Avon longitudinal study of pregnancy and childhood. OUTCOME MEASURES: The percentage of mothers reporting any of 16 common conditions since the birth of their child and the proportion of them who consulted the GP if a condition was reported. chi 2 tests of independence were used to examine the association between condition specific morbidity and social, demographic, and maternal characteristics. Latent class analysis was used to "cluster" mothers according to the particular configuration of social, demographic, and maternal characteristics associated with levels of morbidity for each of the six most commonly reported conditions. The probability of consulting a GP was then compared between clusters. RESULTS: Relative deprivation had a greater impact on morbidity and GP consultation for stress related conditions such as depression, anxiety, and headache/migraine. For all these conditions, higher levels of self reported morbidity and a greater probability of consulting the doctor were associated with a cluster of social disadvantage-living in rented accommodation, non-employment, younger age, and lower educational status. For other conditions such as backache, haemorrhoids, and cough/cold, however, higher morbidity was associated with a cluster of advantage-home ownership, uncrowded living conditions, use of car, and partner in employment. Where there was variation in the probability of consulting the GP for these conditions, it was linked to parity rather than socioeconomic factors. Higher levels of morbidity for all but one condition (backache) were also associated with having more than one child, but this cross-cut socioeconomic and demographic cluster characteristics; both more affluent, older mothers and younger, more deprived mothers were likely to be multiparous. CONCLUSIONS: Relative deprivation was associated with poorer mental but not physical health for this population of mothers of young children. These findings have implications for a more targeted approach to reducing inequality in health. The importance of examining inequality in health for women in relation to their own material circumstances, their employment status, and parity, is emphasised.     

Morbidity and Irish Catholic descent in Britain: relating health disadvantage to behaviour

Objectives. This paper critically evaluates the evidence for two health-related stereotypes of the Irish, namely that behaviours such as smoking and heavy drinking explain their excess morbidity in Britain, and secondly that, in illness, this ethnic group behaves more stoically. Design. Data are reported on over 850 respondents from each of three cohorts (aged 18, 39 and 58 in 1990/91) of the West of Scotland 20-07 Study, in which a small but pervasive excess of morbidity has been observed in those of Catholic background (in this area associated with Irish descent). Logistic regression was used to investigate any differences in drinking, smoking and participation in sport between those of Catholic and non-Catholic heritage, whilst controlling for sex and social class. Where a difference was observed, we looked for an association between health-related behaviour and the Catholic morbidity excess for six measures of physical and mental health. Finally, illness behaviour at age 39 and 58 was investigated for those experiencing one of a number of common symptoms in the month prior to interview, by noting whether a general medical practitioner (GP) was consulted. Results. The only difference in health-related behaviour was in the eldest cohort, where an excess of smoking was observed for the Catholics. However, except for lung power, smoking was not able to explain very much, if any, of the Catholic morbidity disadvantage. For most of the symptoms studied, GP consultation rates were similar, although there was a tendency towards Catholic over-consulting. Conclusion. This paper finds minimal evidence in favour of either stereotype: behaviours such as smoking and excess drinking were not strongly associated with the poor morbidity status of the Irish in the population we have studied; neither have the Irish been found to be more stoic in illness. Therefore the stereotypes are not an adequate explanation, nor a necessary correlate, of the frequent finding of raised morbidity in communities of Irish Catholic origin.     

Family involvement in the care of healthy medical outpatients

BACKGROUND: Although the involvement of patients' family members in office visits has been examined extensively, less is known about the involvement of family members in supporting patients' medical care outside of office visits. OBJECTIVE: This study examines two questions: What types of family involvement do family members have in the medical care of relatively healthy older outpatients, and does self-rated health moderate patients' reactions to this family involvement? METHODS: Patients from a large sample of medical practice outpatients (N = 1572) were assessed to determine perceived emotional support, involvement of family members in their medical care, as well as the presence of depressive symptoms. RESULTS: Approximately 50% of patients had some family involvement in their medical care (e.g. taking part in medical decisions, reminding the patient to take medication). Marital status was a stronger predictor of family involvement than self-ratings of poor physical health. Additionally, there was no evidence that older patients who report good health have less favourable reactions to family involvement in their medical care. CONCLUSION: Family involvement in medical care occurs routinely and is most likely to involve a spouse, and is consistent with family interaction patterns among older adults. These findings also suggest that when providers invite family members to support treatment outside the office visit, these invitations are appropriate for older adult patients across a continuum of good to poor health.     

中国老年居民多种慢性病共存状况分析

  目的  了解山东省农村老年人多重慢性病患病对自评健康的影响,为老年慢性病防治工作提供参考依据。  方法  于2017年8 — 9月采用多阶段分层随机抽样方法在山东省菏泽、潍坊、威海3个地级市抽取7070名 ≥ 60岁常住老年人进行问卷调查,分析其中5514名农村老年人的多重慢性病患病情况及其对自评健康的影响。  结果  山东省5514名农村老年人中,多重慢性病患者1 902例,多重慢性病患病比例为34.5 %;自评健康者2878人,自评健康率为52.19 %。多因素非条件logistic回归分析结果显示,在调整了性别、年龄、文化程度、家庭年均收入、吸烟情况和饮酒情况等混杂因素后,山东省患1种慢性病农村老年人自评不健康的风险为未患慢性病老年人的2.947倍（OR = 2.947,95 % CI = 2.547～3.404）,患多重慢性病老年人自评不健康的风险为未患慢性病老年人的6.675倍（OR = 6.675,95 % CI = 5.735～7.746）。  结论  山东省农村老年人多重慢性病患病比例较高,多重慢性病患病会对老年人自评健康产生消极影响。     

An evaluation of child health clinic services in Newcastle upon Tyne during 1972-1974.

The community child health clinics continued to provide an important and popular service for mothers with young children in Newcastle during 1972-1974, supplementing the primary care services of general practitioners as only a minority of them had undertaken the preventive aspects of child care. Most of the work of the community clinics was done by health visitors and it consisted of advice, support, and reassurance about the everyday problems of children. Although an appreciable amount of the work of the community doctors was developmental screening (birthday checks) most mothers consulted them about relatively minor medical complaints--such as feeding difficulties, specific developmental problems, and immunisation. There was no attempt to do a birthday check on all the children in the city and those that were done revealed few significant undetected abnormalities because most of the children had already attended clinics. In a poor area of the city, family and social problems were often found but very little consultation took place between health and social services, indicating the need for better liaison between these services. The community child health clinics will need to be maintained if general practitioners cannot provide these services and are unable to include preventive as well as curative child care within their practice.     

The impact of type 2 diabetes mellitus on daily functioning.

BACKGROUND: Traditionally, health and the outcomes of medical treatment have been measured in terms of morbidity, incidence or prevalence of disease, or even mortality. This disease model provides an adequate framework for acute illnesses, but for chronic diseases, severity and their effect on everyday functioning are paramount. For chronic diseases, functional health status, as a vital part of quality of life, is now recognized as an important outcome measure of the GP's care. OBJECTIVE: We aimed to assess the impact of type 2 diabetes mellitus on functional health status in Dutch general practice. METHOD: We conducted a cross-sectional study of the functional health status of all patients with type 2 diabetes mellitus under 85 in two general practices, using the Sickness Impact Profile (SIP) and the COOP/WONCA charts. A control group of non-diabetic patients was selected, matched for practice, sex and age. RESULTS: In total, 127 type 2 diabetes mellitus patients and 127 controls participated in the study, the responses being 78 and 70%, respectively. Between these groups the following were significantly different: the SIP subscore Physical, the SIP sum score and the COOP/WONCA scores for physical fitness and overall health. Type 2 diabetes mellitus patients were 2.46 (95% CI 1.5-4.1) times more likely to experience functional impairment. Cardiovascular morbidity (odds ratio 2.5, 95% CI 1.3-4.7), locomotory morbidity (odds ratio 2.6, 95% CI 1.4-5.1) and diabetes itself (odds ratio 1.4, 95% CI 1.1-1.9) were significantly associated with the presence of functional impairment. CONCLUSION: This study demonstrates the impact of type 2 diabetes mellitus on functional status, particularly in relation to cardiovascular morbidity.     

Relationship of disability prevention to patient health status and satisfaction with primary care provider

A sample of 625 patients aged 18 to 65 with primary care visits was used to explore the relationship of disability prevention to patient health status and satisfaction with health care provider. Disability prevention and the patient-provider relationship, the latter a potential mediating factor, were measured using reliable and valid scales. The joint effects of disability prevention and a strong patient-provider relationship were associated with decreased risks for poor physical health, as measured by the Medical Outcomes Study 12-item short-form health survey, decreased restricted activity days, and overall satisfaction with their primary care provider. Patient-provider relationship was independently associated with increased patient satisfaction with the provider overall and endorsement of the provider to family or friends. The evidence questions the conventional wisdom among some primary care providers that incorporating disability prevention principles into their daily practice jeopardizes patient satisfaction. These results suggest that primary care providers with strong patient-provider relationships can successfully add disability prevention to their practice.     

The Marks Asthma Quality of Life Questionnaire: further validation and examination of responsiveness to change.

We performed analyses to examine the structure, validity, and responsiveness to change of the Marks Asthma Quality of Life Questionnaire (AQLQ), originally validated in Australia in a self-administered format, among 539 U.S. subjects with asthma. Subjects were interviewed twice by telephone over an 18-month period. Based on factor analyses, the subscale structure of the AQLQ was modified slightly to eliminate item overlap among subscale scores. Cross-sectionally, total AQLQ scores were significantly correlated in expected directions with baseline asthma severity scores (r = 0.58), SF-36 physical (r = -0.66) and mental (r = -0.40) health status scores, and pulmonary function (FEV1% predicted, r = -0.14). Longitudinally, changes in AQLQ total and subscale scores were significantly (P<0.01) associated with changes in asthma severity and both physical and mental status. The AQLQ, administered by telephone, appears to be useful for assessing changes in the impact of adult asthma.     

Marginal impact of psychosocial factors on multimorbidity: results of an explorative nested case-control study

This study examines differences between subjects with zero, one or two or more new diseases in a period of three years, with regard to demographic characteristics, socioeconomic status, life style, medical family history and current diseases in the family, psychological and sociological characteristics. This was studied using a primary care based nested case-control study. Data were available from 3745 cases and controls, all aged 20 years and older. All subjects were sampled from the Registration Network Family Practices, which is a computerised continuous primary care database. Cases were defined as subjects with new multimorbidity (two or more new diseases) registered in a period of three years and two groups of controls were operationalised as subjects with either one or no new diseases registered in the same period. Determinants were assessed by means of a postal questionnaire. Increasing age, higher number of previous diseases and low socioeconomic status were strongly associated with both morbidity and multimorbidity. After adjustment for these basic variables, the occurrence of multimorbidity was more frequent among subjects who did not report (volunteer) work or study, who had an active coping style, a high occupational class and an external locus of control. Profiles for subjects at risk for morbidity and multimorbidity seem to differ.     

A cost-utility analysis of nursing intervention via telephone follow-up for injured road users

Background

Multimorbidity is a highly frequent condition in older people, but well designed longitudinal studies on the impact of multimorbidity on patients and the health care system have been remarkably scarce in numbers until today. Little is known about the long term impact of multimorbidity on the patients' life expectancy, functional status and quality of life as well as health care utilization over time. As a consequence, there is little help for GPs in adjusting care for these patients, even though studies suggest that adhering to present clinical practice guidelines in the care of patients with multimorbidity may have adverse effects.

Methods/Design

The study is designed as a multicentre prospective, observational cohort study of 3.050 patients aged 65 to 85 at baseline with at least three different diagnoses out of a list of 29 illnesses and syndromes. The patients will be recruited in approx. 120 to 150 GP surgeries in 8 study centres distributed across Germany. Information about the patients' morbidity will be collected mainly in GP interviews and from chart reviews. Functional status, resources/risk factors, health care utilization and additional morbidity data will be assessed in patient interviews, in which a multitude of well established standardized questionnaires and tests will be performed.

Discussion

The main aim of the cohort study is to monitor the course of the illness process and to analyse for which reasons medical conditions are stable, deteriorating or only temporarily present. First, clusters of combinations of diseases/disorders (multimorbidity patterns) with a comparable impact (e.g. on quality of life and/or functional status) will be identified. Then the development of these clusters over time will be analysed, especially with regard to prognostic variables and the somatic, psychological and social consequences as well as the utilization of health care resources. The results will allow the development of an instrument for prediction of the deterioration of the illness process and point at possibilities of prevention. The practical consequences of the study results for primary care will be analysed in expert focus groups in order to develop strategies for the inclusion of the aspects of multimorbidity in primary care guidelines.     

Body mass index and socioeconomic position are associated with 9-year trajectories of multimorbidity: A population-based study

Multimorbidity is a growing public health problem and is more common in women than men. However, little is known about multimorbidity trajectories, in terms of the accumulation of disease over time, or about the determinants of these trajectories. We sought to identify lifestyle and socioeconomic factors related to multimorbidity trajectories in mid-aged women. Participants were from the Australian Longitudinal Study on Women's Health, a nationally representative population-based study. We included 4865 women born 1946–51, without chronic disease in 1998, followed triennially for 12 years. We used latent class growth analysis to identify 9-year multimorbidity trajectories and multinomial regression to calculate relative risk ratios (RRRs) for associations between baseline lifestyle and socioeconomic factors and trajectories. We identified five multimorbidity trajectories: ‘no morbidity, constant’; ‘low morbidity, constant’; ‘moderate morbidity, constant’; ‘no morbidity, increasing’; and ‘low morbidity, increasing’. Overweight and obesity were associated with an increased risk of the ‘no morbidity, increasing’ (RRR 1.70, 95% CI 1.16 to 2.50 and 2.69, 95% CI 1.69 to 4.28, respectively) and the ‘low morbidity, increasing’ (RRR 2.57, 95% CI 1.56 to 4.24 and 4.28, 95% CI 2.41 to 7.60, respectively) trajectories, as compared to the ‘no morbidity, constant’ group. Low education and difficulty managing on income were also associated with trajectories of poorer health. Among mid-aged women, overweight/obesity and lower socioeconomic status are major risk factors for trajectories characterised by accumulation of chronic disease. These highlight key target areas for preventive approaches aimed at reducing the risk of accumulation of morbidities in mid-aged women.