社区老年慢性病共存患者治疗负担现状及影响因素研究

背景　随着我国老龄化进程的增快,老年人口增多,老年慢性病共存患者增多,慢性病共存引起的治疗负担给患者带来诸多不利影响。目的　了解我国社区老年慢性病共存患者治疗负担现状及影响因素。方法　2019年9-12月采用便利抽样法选取郑州市两家社区卫生服务中心下属社区的370例老年慢性病共存患者为调查对象。运用一般资料调查问卷、慢性病共存治疗负担问卷进行调查。采用有序Logistic回归分析社区老年慢性病共存患者治疗负担的影响因素。结果　回收有效问卷350份,有效回收率为94.6%。350例调查对象中,4例（1.1%）没有治疗负担,47例（13.4%）低度治疗负担,173例（49.4%）中度治疗负担,126例（36.0%）高度治疗负担。有序Logistic回归分析结果显示,家庭人均月收入、医保类型、慢性病数量、查尔森合并症指数（CCI）分级是社区老年慢性病共存患者治疗负担的影响因素（P<0.05）。结论　社区老年慢性病共存患者治疗负担大部分处于中高度水平,治疗负担较重。应重点关注家庭收入低、慢性病数量多、CCI分级高、医保类型为新型农村合作医疗的老年慢性病共存患者,国家应加大医保报销比例、范围,医务人员应加强健康教育等针对性的干预措施,减轻老年慢性病共存患者的治疗负担。     

Patient priorities and the doorknob phenomenon in primary care: Can technology improve disclosure of patient stressors?

Objective

Patients with multiple chronic conditions face many stressors (e.g. financial, safety, transportation stressors) that are rarely prioritized for discussion with the primary care provider (PCP). In this pilot randomized controlled trial we examined the effects of a novel technology-based intervention called Customized Care on stressor disclosure.

Cancer-specific administrative data–based comorbidity indices provided valid alternative to Charlson and National Cancer Institute Indices

ObjectiveWe aimed to develop and validate administrative data–based comorbidity indices for a range of cancer types that included all relevant concomitant conditions.Study Design and SettingsPatients diagnosed with colorectal, breast, gynecological, upper gastrointestinal, or urological cancers identified from the National Cancer Registry between July 1, 2006 and June 30, 2008 for the development cohort (n = 14,096) and July 1, 2008 to December 31, 2009 for the validation cohort (n = 11,014) were identified. A total of 50 conditions were identified using hospital discharge data before cancer diagnosis. Five site-specific indices and a combined site index were developed, with conditions weighted according to their log hazard ratios from age- and stage-adjusted Cox regression models with noncancer death as the outcome. We compared the performance of these indices (the C3 indices) with the Charlson and National Cancer Institute (NCI) comorbidity indices.ResultsThe correlation between the Charlson and C3 index scores ranged between 0.61 and 0.78. The C3 index outperformed the Charlson and NCI indices for all sites combined, colorectal, and upper gastrointestinal cancer, performing similarly for urological, breast, and gynecological cancers.ConclusionThe C3 indices provide a valid alternative to measuring comorbidity in cancer populations, in some cases providing a modest improvement over other indices.     

Health and treatment priorities in patients with multimorbidity: Report on a workshop from the European General Practice Network meeting ‘Research on multimorbidity in general practice’

Abstract

Setting health and treatment priorities is necessary when caring for multiple and complex patient issues. This is already done in the doctorpatient consultation—yet implicitly rather than explicitly. The aim of this European General Practice Network workshop was to advance a consultation approach that deals with shared priority setting. The workshop was divided into three parts: (1) how to gain a comprehensive health overview for patients with multiple problems as a basis for priority setting; (2) how to establish priorities considering patient and doctor perspectives; and (3) how to practice a communication style that achieves shared priority setting. The workshop participants preferred to gain information on patients’ health status using documentations from patient records rather than conducting systematic assessments. The group emphasized that medical as well as everyday life problems need to be considered when determining priorities, a procedure that requires time and resources not readily available in daily practice. Existing skills for person-centred communication with patients should be applied in order to agree on priorities. Overall it became apparent how challenging it is to arrange and prioritize an array of health problems in a consultation with patients. Existing concepts augmented by innovative systematic methods may be the way forward.     

Development of a new predictive model for polypathological patients. The PROFUND index

Background

There is a concern about the accuracy of the available prognostic indexes when applying them to the emergent population of polypathological patients (PP).

Methods

To develop a 1-year mortality predictive index on PP, we developed a multicenter prospective cohort-study recruiting 1.632 PP after hospital discharge, outpatient clinics, or home hospitalization, from 33 hospitals. Potential risk factors were obtained in the 1.525 PP who completed follow-up. Each factor independently associated with mortality in the derivation cohort (757 PP from western hospitals) was assigned a weight, and risk scores were calculated by adding the points of each factor. Accuracy was assessed in the validation cohort (768 PP from eastern hospitals) by risk quartiles calibration, and discrimination power, by ROC curves. Finally, accuracy of the index was compared with that of the Charlson index.

Results

Mortality in the derivation/validation cohorts was 35%/39.5%, respectively. Nine independent mortality predictors were identified to create the index (age ≥ 85 years, 3points; No caregiver or caregiver other than spouse, 2points; active neoplasia, 6points; dementia, 3points; III-IV functional class on NYHA and/or MRC, 3points; delirium during last hospital admission, 3points; hemoglobinemia < 10 g/dl, 3points; Barthel index < 60 points, 4points; ≥ 4 hospital admissions in last 12 months, 3points). Mortality in the derivation/validation cohorts was 12.1%/14.6% for patients with 0-2points; 21.5%/31.5% for those with 3-6 points; 45%/50% for those with 7-10 points; and 68%/61.3% for those with ≥ 11points, respectively. Calibration was good in derivation/validation cohorts, and discrimination power by area under the curve was 0.77/0.7. Calibration of the Charlson index was good, but discrimination power was suboptimal (area under the curve, 0.59).

Conclusions

This prognostic index provides an accurate and transportable method of stratifying 1-year death risk in PP.     

A multi-institutional, hospital-based assessment of clinical, functional, sociofamilial and health-care characteristics of polypathological patients (PP)

Little is known about the main features of the emergent population of PP. Our objective was to determine the clinical, care and social characteristics of a multi-institutional population of PP, by means of a cross-sectional study including a reference population of hospital-based PP from 36 hospitals. The main clinical, functional, mental and social features and their associated factors were assessed: 1632 PP (53% males, mean age 77.9 ± 9.8 years) were included. An informal caregiver was required by 52% (78% of caregivers were close female relatives). The mean inclusion criteria (Cat): were 2.7 ± 0.8 (49.5% presented ≥3 Cat). The most frequent inclusion Cat were heart (77.5%), lung (45.6%), neurological (38.2%), and kidney diseases (32.2%), whereas the mean of other comorbidities was 4.5 ± 2.7 per PP. The mean Charlson comorbidity index (CCI) was 4; 47.6%, and 52.4% presented dyspnea ≥3 on the NYHA, and on the MRC, respectively; nearly 19% required home oxygen therapy, 19% had suffered >1 fall in previous year, and 11% suffered an active neoplasia. The mean hospital admissions in last 12/3 months, and chronically prescribed drugs were 2/1, and 8 ± 3, respectively. More than 70% presented obesity, while 60% had hypoalbuminemia. The basal/inclusion Barthel index (BI) score was 69 ± 31/58 ± 34 (BI score < 60 was present in 31.5%/44%, respectively); and the mean Pfeiffer score was 2.94 ± 3.2 (43% answered with ≥3 errors). More than half of the subjects were at risk or already had established social problems. This emergent population is considerably homogeneous, highly complex, clinically vulnerable, functionally impaired, dependent on caregivers and socially fragile. They need to receive more attention in clinical research and more support in health interventions based on comprehensive attention and continuity of care.     

Self-management across chronic diseases: Targeting education and support needs

ObjectivesAmong Canadian adults with chronic disease: 1) to identify groups that differ in self-management task frequency and self-efficacy; 2) to compare group characteristics and preferences for self-management support.MethodsUsing data from an online survey, cluster analysis was used to identify groups that differed in self-management task frequency and self-efficacy. Multivariable regression was used to explore relationships with patient characteristics and preferences.ResultsCluster analysis (n = 247) revealed three groups:Vulnerable Self-Managers (n = 55), with the highest task frequency and lowest self-efficacy; Confident Self-Managers (n = 73), with the lowest task frequency and highest self-efficacy; and Moderate Needs Self-Managers (n = 119), with intermediate task frequency and self-efficacy. Vulnerable Self-Managers, when compared with the Confident group, were more often: on illness-related employment disability or unemployed; less well educated; diagnosed with emotional problems or hypertension, and had greater multimorbidity. They participated less often in self-management programs, and differed in support preferences.ConclusionsKnowing the characteristics of vulnerable self-managers can help in targeting those in greater need for self-management support that matches their preferences.Practice ImplicationsDifferent approaches are needed to support self-management in the vulnerable population.