Comorbidity: Implications for the Importance of Primary Care in 'Case' Management (original) (raw)
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Comorbidity and the Use of Primary Care and Specialist Care in the Elderly
The Annals of Family Medicine, 2005
PURPOSE The impact of comorbidity on use of primary care and specialty services is poorly understood. The purpose of this study was to determine the relationship between morbidity burden, comorbid conditions, and use of primary care and specialist services METHODS The study population was a 5% random sample of Medicare beneficiaries, taken from 1999 Medicare fi les. We analyzed the number of ambulatory face-to-face patient visits to primary care physicians and specialists for each diagnosis, with each one fi rst considered as the "main" one and then as a comorbid diagnosis to another. Each patient was categorized by extent of total morbidity burden using the Johns Hopkins Adjusted Clinical Group case-mix system.
2021
Background. Comorbidity is increasingly important in the medical literature, with ever-increasing impacts as populations age. Comorbidity has multiple and complex implications for the processes of diagnosis, treatment, prognosis, management and health care. The objective of this study is to measure casual versus causal comorbidity in primary care in three family practice populations. Methods. This is a longitudinal observational study using the Transition Project datasets. Transition Project family doctors in the Netherlands, Malta and Serbia recorded details of all patient contacts in an episode of care structure using electronic medical records and the International Classi cation of Primary Care, collecting data on all elements of the doctor-patient encounter, including diagnoses (1,178,178 in the Netherlands, 93,606 in Malta, 405,150 in Serbia), observing 158,370 patient years in the Netherlands, 43,577 in Malta, 72,673 in Serbia. Comorbidity was measured using the odds ratio of both conditions being incident or rest-prevalent in the same patient in one-year dataframes, as against not. Results. Comorbidity in family practice in the three population databases is expressed as odds ratios between the 41 joint most prevalent (joint top 20) episode titles in the three populations. Speci c associations were explored in different age groups to observe the changes in odds ratios with increasing age as a surrogate for a temporal or biological gradient. Conclusion. After applying accepted criteria for testing the causality of associations, it is reasonable to conclude that most observed primary care comorbidity is casual. It would be incorrect to assume causal relationships between co-occurring diseases in family medicine, even if such a relationship might be plausible or consistent with current conceptualisations of the causation of disease. Most observed comorbidity in primary care is the result of increasing illness diversity. Trial registration. This study was performed on electronic patient record datasets made publicly available by the University of Amsterdam Department of General Practice, and did not involve any patient intervention. Funding. Self-funded.
Impact of comorbidity on the individual's choice of primary health care provider
Scandinavian Journal of Primary Health Care, 2011
Objective. This study examined whether age, gender, and comorbidity were of importance for an individual ' s choice of listing with either a public or a private primary health care (PHC) practice. Design and setting. The study was a registerbased closed cohort study in one private and one public PHC practice in Blekinge County in southern Sweden. Subject s. A cohort (12 696 individuals) was studied comprising all those listed with the public or private PHC practice on 1 October 2005 who were also listed with the public PHC practice on 1 October 2004. Main outcome measures. The listing/re-listing behaviour of the population in this cohort was studied at two points in time, 1 October 2005 and 1 October 2006, with respect to age, gender, and comorbidity level as measured by the ACG Case-Mix system. Results. Individuals listed with the public practice both on 1 October 2005 and one year later were signifi cantly older, were more often females, and had a higher comorbidity level than individuals listed with the private practice. Individuals with a higher comorbidity level were more likely to re-list or to stay listed with the public practice. Conclusions. This study shows that the probability of choosing a public instead of private PHC provider increased with higher age and comorbidity level of the individuals. It is suggested that using a measure of comorbidity can help us understand more about the chronically ill individual ' s choice of health care provider. This would be of importance when health care policy-makers decide on reimbursement system or organization of PHC.
Comorbidity Patterns in Patients with Chronic Diseases in General Practice
PLoS ONE, 2012
Introduction: Healthcare management is oriented toward single diseases, yet multimorbidity is nevertheless the rule and there is a tendency for certain diseases to occur in clusters. This study sought to identify comorbidity patterns in patients with chronic diseases, by reference to number of comorbidities, age and sex, in a population receiving medical care from 129 general practitioners in Spain, in 2007.
International Journal of Clinical Practice, 2013
Aim: To assess whether participation in a series of continuing medical educationcertified activities presenting complicated case scenarios resulted in evidence-based decision making for patients with chronic comorbid conditions. Methods: A series of interactive live workshops and online case studies presented evidence-based, practical information addressing the care of patients with multiple chronic diseases to primary care physicians. Clinical case vignettes were used to assess workshop participant knowledge and competence. Results were compared with those of matched non-participant controls. Online participants were surveyed to evaluate immediate knowledge gains from the activity. Results: Overall, physician workshop participants were 27% more knowledgeable of evidence-based treatment decisions. Participants were more likely to refer a patient with rheumatoid arthritis to a rheumatologist (57% vs. 36%; p = 0.035) and showed better recognition of medications that can contribute to overactive bladder symptoms (36% vs. 18%; p = 0.043) compared with non-participant controls. Non-significant differences in favour of participants included evidence-based decisions regarding the management of osteoporosis, attention deficit hyperactivity disorder in adults and type 2 diabetes mellitus in adolescents. Online participants demonstrated significant knowledge gains (p < 0.001) on 17 of 18 assessment questions across all therapeutic areas. Discussion: Chronic comorbid conditions afflict a sizable minority of patients. However, specific recommendations and education surrounding patient management are often overlooked because of the inherent difficulty of treating this group. Highly interactive educational activities can improve participant knowledge and competency in treating these patients by providing an opportunity to interact with faculty experts, receive immediate feedback and practice new skills. Conclusion: Interactive educational activities that discuss complicated case scenarios can improve participant application of evidence-based medicine for patients with multiple chronic comorbidities.
Comorbidity of chronic diseases in general practice
Journal of Clinical Epidemiology, 1993
With the increasing number of elderly people in The Netherlands the prevalence of chronic diseases will rise in the next decades. It is recognized in general practice that many older patients suffer from more than one chronic disease (comorbidity). The aim of this study is to describe the extent of comorbidity for the following diseases: hypertension, chronic ischemic heart disease, diabetes mellitus, chronic nonspecific lung disease, osteoarthritis. In a general practice population of 23,534 persons, 1989 patients have been identified with one or more chronic diseases. Only diseases in agreement with diagnostic criteria were included. In persons of 65 and older 23% suffer from one or more of the chronic diseases under study. Within this group 15% suffer from more than one of the chronic diseases. Osteoarthritis and diabetes mellitus are the diseases with the highest rate of comorbidity. Comorbidity restricts the external validity of results from single-disease intervention studies and complicates the organization of care.
Healthcare policy = Politiques de santé, 2014
Specialist physicians may act either as consultants or co-managers for patients with chronic diseases along with their primary healthcare (PHC) physician. We assessed factors associated with specialist involvement. We used questionnaire and administrative data to measure co-management and patient and PHC practice characteristics in 702 primary care patients with common chronic diseases. Analysis included multilevel logistic regressions. In all, 27% of the participants were co-managed. Persons with more severe chronic diseases and lower health-related quality of life were more likely to be co-managed. Persons who were older, had a lower socioeconomic status, resided in rural regions and who were followed in a PHC practice with an advanced practice nurse were less likely to be co-managed. Co-management of patients with chronic diseases by a specialist is associated with higher clinical needs but demonstrates social inequalities. PHC practices more adapted to chronic care may help opti...
Defining Comorbidity: Implications for Understanding Health and Health Services
The Annals of Family Medicine, 2009
Comorbidity is associated with worse health outcomes, more complex clinical management, and increased health care costs. There is no agreement, however, on the meaning of the term, and related constructs, such as multimorbidity, morbidity burden, and patient complexity, are not well conceptualized. In this article, we review defi nitions of comorbidity and their relationship to related constructs. We show that the value of a given construct lies in its ability to explain a particular phenomenon of interest within the domains of (1) clinical care, (2) epidemiology, or (3) health services planning and fi nancing. Mechanisms that may underlie the coexistence of 2 or more conditions in a patient (direct causation, associated risk factors, heterogeneity, independence) are examined, and the implications for clinical care considered. We conclude that the more precise use of constructs, as proposed in this article, would lead to improved research into the phenomenon of ill health in clinical care, epidemiology, and health services.