Impact of multimorbidity and complex multimorbidity on healthcare utilisation in older Australian adults aged 45 years or more: a large population-based cross-sectional data linkage study.

OBJECTIVES: As life expectancy increases, older people are living longer with multimorbidity (MM, co-occurrence of ≥2 chronic health conditions) and complex multimorbidity (CMM, ≥3 chronic conditions affecting ≥3 different body systems). We assessed the impacts of MM and CMM on healthcare service use in Australia, as little was known about this. DESIGN: Population-based cross-sectional data linkage study. SETTING: New South Wales, Australia. PARTICIPANTS: 248 496 people aged ≥45 years who completed the Sax Institute's 45 and Up Study baseline questionnaire. PRIMARY OUTCOME: High average annual healthcare service use (≥2 hospital admissions, ≥11 general practice visits and ≥2 emergency department (ED) visits) during the 3-year baseline period (year before, year of and year after recruitment). METHODS: Baseline questionnaire data were linked with hospital, Medicare claims and ED datasets. Poisson regression models were used to estimate adjusted and unadjusted prevalence ratios for high service use with 95% CIs. Using a count of chronic conditions (disease count) as an alternative morbidity metric was requested during peer review. RESULTS: Prevalence of MM and CMM was 43.8% and 15.5%, respectively, and prevalence increased with age. Across three healthcare settings, MM was associated with a 2.02-fold to 2.26-fold, and CMM was associated with a 1.83-fold to 2.08-fold, increased risk of high service use. The association was higher in the youngest group (45-59 years) versus the oldest group (≥75 years), which was confirmed when disease count was used as the morbidity metric in sensitivity analysis.When comparing impact using three categories with no overlap (no MM/CMM, MM with no CMM, and CMM), CMM had greater impact than MM across all settings. CONCLUSION: Increased healthcare service use among older adults with MM and CMM impacts on the demand for primary care and hospital services. Which of MM or CMM has greater impact on risk of high healthcare service use depends on the analytic method used. Ageing populations living longer with increasing burdens of MM and CMM will require increased Medicare funding and provision of integrated care across the healthcare system to meet their complex needs.

A systematic review on the effectiveness and impact of clinical decision support systems for breathlessness.

Breathlessness is a common presenting symptom in practice. This systematic review aimed to evaluate the impact of CDSS on breathlessness and associated diseases in real-world clinical settings. Studies published between 1 January 2000 to 10 September 2021 were systematically obtained from 14 electronic research databases including CENTRAL, Embase, Pubmed, and clinical trial registries. Main outcomes of interest were patient health outcomes, provider use, diagnostic concordance, economic evaluation, and unintended consequences. The review protocol was prospectively registered in PROSPERO (CRD42020163141). A total of 4294 records were screened and 37 studies included of which 30 were RCTs. Twenty studies were in primary care, 13 in hospital outpatient/emergency department (ED), and the remainder mixed. Study duration ranged from 2 weeks to 5 years. Most were adults (58%). Five CDSS were focused on assessment, one on assessment and management, and the rest on disease-specific management. Most studies were disease-specific, predominantly focused on asthma (17 studies), COPD (2 studies), or asthma and COPD (3 studies). CDSS for COPD, heart failure, and asthma in adults reported clinical benefits such as reduced exacerbations, improved quality of life, improved patient-reported outcomes or reduced mortality. Studies identified low usage as the main barrier to effectiveness. Clinicians identified dissonance between CDSS recommendations and real-world practice as a major barrier. This review identified potential benefits of CDSS implementation in primary care and outpatient services for adults with heart failure, COPD, and asthma in improving diagnosis, compliance with guideline recommendations, promotion of non-pharmacological interventions, and improved clinical outcomes including mortality.

Impact of multimorbidity and complex multimorbidity on mortality among older Australians aged 45 years and over: a large population-based record linkage study.

OBJECTIVES: Multimorbidity (MM, co-occurrence of two or more chronic conditions) and complex multimorbidity (CMM, three or more chronic conditions affecting three or more different body systems) are used in the assessment of complex healthcare needs and their impact on health outcomes. However, little is known about the impacts of MM and CMM on mortality in Australia. DESIGN: Community-based prospective cohort study. SETTING: New South Wales, Australia. PARTICIPANTS: People aged 45 years and over who completed the baseline survey of the 45 and Up Study. MEASURES: Baseline survey data from the 45 and Up Study were linked with deaths registry data. Deaths that occurred within 8 years from the baseline survey date were the study outcome. Eleven self-reported chronic conditions (cancer, heart disease, diabetes, stroke, Parkinson's disease, depression/anxiety, asthma, allergic rhinitis, hypertension, thrombosis and musculoskeletal conditions) from the baseline survey were included in the MM and CMM classifications. Cox proportional hazard models were used to estimate adjusted and unadjusted 8-year mortality hazard ratios (HRs). RESULTS: Of 251 689 people (53% female and 54% aged ≥60 years) in the cohort, 111 084 (44.1%) were classified as having MM and 39 478 (15.7%) as having CMM. During the 8-year follow-up, there were 25 891 deaths. Cancer (34.7%) was the most prevalent chronic condition and the cardiovascular system (50.9%) was the body system most affected by a chronic condition. MM and CMM were associated with a 37% (adjusted HR 1.36, 95% CI 1.32 to 1.40) and a 22% (adjusted HR 1.22, 95% CI 1.18 to 1.25) increased risk of death, respectively. The relative impact of MM and CMM on mortality decreased as age increased. CONCLUSION: MM and CMM were common in older Australian adults; and MM was a better predictor of all-cause mortality risk than CMM. Higher mortality risk in those aged 45-59 years indicates tailored, person-centred integrated care interventions and better access to holistic healthcare are needed for this age group.

Toolkits for implementing and evaluating digital health: A systematic review of rigor and reporting.

OBJECTIVE: Toolkits are an important knowledge translation strategy for implementing digital health. We studied how toolkits for the implementation and evaluation of digital health were developed, tested, and reported. MATERIALS AND METHODS: We conducted a systematic review of toolkits that had been used, field tested or evaluated in practice, and published in the English language from 2009 to July 2019. We searched several electronic literature sources to identify both peer-reviewed and gray literature, and records were screened as per systematic review conventions. RESULTS: Thirteen toolkits were eventually identified, all of which were developed in North America, Europe, or Australia. All reported their intended purpose, as well as their development process. Eight of the 13 toolkits involved a literature review, 3 did not, and 2 were unclear. Twelve reported an underlying conceptual framework, theory, or model: 3 cited the normalization process theory and 3 others cited the World Health Organization and International Telecommunication Union eHealth Strategy. Seven toolkits were reportedly evaluated, but details were unavailable. Forty-three toolkits were excluded for lack of field-testing. DISCUSSION: Despite a plethora of published toolkits, few were tested, and even fewer were evaluated. Methodological rigor was of concern, as several did not include an underlying conceptual framework, literature review, or evaluation and refinement in real-world settings. Reporting was often inconsistent and unclear, and toolkits rarely reported being evaluated. CONCLUSION: Greater attention needs to be paid to rigor and reporting when developing, evaluating, and reporting toolkits for implementing and evaluating digital health so that they can effectively function as a knowledge translation strategy.

Quality assessment of real-world data repositories across the data life cycle: A literature review.

OBJECTIVE: Data quality (DQ) must be consistently defined in context. The attributes, metadata, and context of longitudinal real-world data (RWD) have not been formalized for quality improvement across the data production and curation life cycle. We sought to complete a literature review on DQ assessment frameworks, indicators and tools for research, public health, service, and quality improvement across the data life cycle. MATERIALS AND METHODS: The review followed PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Databases from health, physical and social sciences were used: Cinahl, Embase, Scopus, ProQuest, Emcare, PsycINFO, Compendex, and Inspec. Embase was used instead of PubMed (an interface to search MEDLINE) because it includes all MeSH (Medical Subject Headings) terms used and journals in MEDLINE as well as additional unique journals and conference abstracts. A combined data life cycle and quality framework guided the search of published and gray literature for DQ frameworks, indicators, and tools. At least 2 authors independently identified articles for inclusion and extracted and categorized DQ concepts and constructs. All authors discussed findings iteratively until consensus was reached. RESULTS: The 120 included articles yielded concepts related to contextual (data source, custodian, and user) and technical (interoperability) factors across the data life cycle. Contextual DQ subcategories included relevance, usability, accessibility, timeliness, and trust. Well-tested computable DQ indicators and assessment tools were also found. CONCLUSIONS: A DQ assessment framework that covers intrinsic, technical, and contextual categories across the data life cycle enables assessment and management of RWD repositories to ensure fitness for purpose. Balancing security, privacy, and FAIR principles requires trust and reciprocity, transparent governance, and organizational cultures that value good documentation.

A digital health profile & maturity assessment toolkit: cocreation and testing in the Pacific Islands.

INTRODUCTION: Countries need to determine their level of digital health capability maturity to assess and mobilize their knowledge, skills, and resources to systematically develop, implement, evaluate, scale up and maintain large-scale implementations of standards-based interoperable digital health tools. OBJECTIVE: Develop a Digital Health Profile and Maturity Assessment Toolkit (DHPMAT) to assist Pacific Island Countries (PICs) to harness digital tools to support national health priorities. MATERIALS AND METHODS: A literature review guided the development of the conceptual framework to underpin the DHPMAT. Key informants collaborated to collect key digital health features and indicators to inform their country's digital health maturity assessment. The DHPMAT was tested with country stakeholders at a Pacific Health Information Network workshop in 2019. RESULTS: A comprehensive list of indicators to describe country digital health profiles (DHP). A digital health maturity assessment tool that uses criteria codeveloped with country stakeholders to assess essential digital health foundations and quality improvement. DHPs created and maturity assessed and packaged into individualized DHPMATs for 13 PICs. PIC users perceived the DHPMAT as useful, especially the congruence with the 2017 WHO WPRO Regional Strategy but noted a "cognitive overload" from a plethora of complex digital health toolkits. CONCLUSIONS: The cocreation approach optimized currency, accuracy, and appropriateness of information in the DHP, understanding, and use of the DHPMAT to facilitate informed iterative discussion by PICs on their digital health maturity to harness digital tools to strengthen country health systems. The DHPMAT can rationalize the choice and use of existing tools and reduce cognitive overload.

Activating primary care COPD patients with multi-morbidity through tailored self-management support.

Given the dearth of COPD self-management interventions that specifically acknowledge multi-morbidity in primary care, we aimed to activate COPD patients through personalised self-management support that recognised the implications of co-morbidities. This single-group experimental study included patients aged 40-84 with a spirometry diagnosis of COPD and at least one co-morbidity. A self-management education programme for COPD in the context of multi-morbidity, based on the Health Belief Model, was tailored and delivered to participants by general practice nurses in face-to-face sessions. At 6 months' follow-up, there was significant improvement in patient activation (p < 0.001), COPD-related quality of life (p = 0.012), COPD knowledge (p < 0.001) and inhaler device technique (p = 0.001), with no significant change in perception of multi-morbidity (p = 0.822) or COPD-related multi-morbidity (0.084). The programme improved patients' self-efficacy for their COPD as well as overall health behaviour. The findings form an empirical basis for further testing the programme in a large-scale randomised controlled trial.

Patients' perspectives on the impact of a new COPD diagnosis in the face of multimorbidity: a qualitative study.

BACKGROUND: Chronic obstructive pulmonary disease (COPD), a major cause of morbidity and mortality worldwide, often occurs in the presence of comorbidities, which may influence experience and management of the disease. No prior research seems to have gained perspectives of newly diagnosed primary care COPD patients in the context of multimorbidity. AIMS: This qualitative study aimed to explore the impact of a new diagnosis of COPD in the context of multimorbidity and also sought to gain a better understanding of how patients react to the diagnosis and incorporate it into their lives. METHODS: Participants were identified from a cohort of primary care patients with multimorbidity recently diagnosed with COPD. Data was collected via semi-structured interviews from nine male and eight female participants. Thematic analysis was performed and the data interpreted from a constructivist perspective. RESULTS: Five core themes regarding COPD were induced: (i) reaction to diagnosis, (ii) impact on function and health behaviour, (iii) factors influencing self-management capacity, (iv) healthcare utilisation and (v) interplay of comorbidities. Most participants had difficulty recognising the importance of COPD and its long-term implications. For many, the salience of another chronic condition outweighed COPD. Self-management capacity and utilisation of healthcare services were challenged by low prioritisation of COPD among other comorbidities. CONCLUSIONS: This study provides an insight into how primary care patients feel about being diagnosed with COPD, as well as their prioritisation of the disease in the context of multimorbidity. It highlights the need for tailored education and personalised management incorporating patients' perspectives in primary care.