Person-Centered Models for Cardiovascular Care: A Review of the Evidence: A Scientific Statement From the American Heart Association.

Cardiovascular disease remains the leading cause of death and disability in the United States and globally. Disease burden continues to escalate despite technological advances associated with improved life expectancy and quality of life. As a result, longer life is associated with multiple chronic cardiovascular conditions. Clinical guidelines provide recommendations without considering prevalent scenarios of multimorbidity and health system complexities that affect practical adoption. The diversity of personal preferences, cultures, and lifestyles that make up one's social and environmental context is often overlooked in ongoing care planning for symptom management and health behavior support, hindering adoption and compromising patient outcomes, particularly in groups at high risk. The purpose of this scientific statement was to describe the characteristics and reported outcomes in existing person-centered care delivery models for selected cardiovascular conditions. We conducted a scoping review using Ovid MEDLINE, Embase.com, Web of Science, CINAHL Complete, Cochrane Central Register of Controlled Trials through Ovid, and ClinicalTrials.gov from 2010 to 2022. A range of study designs with a defined aim to systematically evaluate care delivery models for selected cardiovascular conditions were included. Models were selected on the basis of their stated use of evidence-based guidelines, clinical decision support tools, systematic evaluation processes, and inclusion of the patient's perspective in defining the plan of care. Findings reflected variation in methodological approach, outcome measures, and care processes used across models. Evidence to support optimal care delivery models remains limited by inconsistencies in approach, variation in reimbursement, and inability of health systems to meet the needs of patients with chronic, complex cardiovascular conditions.

An expanded chronic care management approach to multiple chronic conditions in Hispanics using community health workers as community extenders in the Rio Grande Valley of Texas.

INTRODUCTION: The synergistic negative effects of type 2 diabetes (T2DM) and hypertension increases all-cause mortality and the medical complexity of management, which disproportionately impact Hispanics who face barriers to healthcare access. The Salud y Vida intervention was delivered to Hispanic adults living along the Texas-Mexico Border with comorbid poorly controlled T2DM and hypertension. The Salud y Vida multicomponent intervention incorporated community health workers (CHWs) into an expanded chronic care management model to deliver home-based follow-up visits and provided community-based diabetes self-management education. METHODS: We conducted multivariable longitudinal analysis to examine the longitudinal intervention effect on reducing systolic and diastolic blood pressure among 3806 participants enrolled between 2013 and 2019. Participants were compared according to their program participation as either higher (≥ 10 combined educational classes and CHW visits) or lower engagement (<10 encounters). Data was collected between 2013 and 2020. RESULTS: Baseline mean systolic and diastolic blood pressure were 138 and 81 mmHg respectively. There were overall improvements in systolic (-6.49; 95% CI = [-7.13, -5.85]; p < 0.001) and diastolic blood pressure (-3.97; 95% CI = [-4.37, -3.56]; p < 0.001). The higher engagement group had greater systolic blood pressure reduction at 3 months (adjusted mean difference = -1.8 mmHg; 95% CI = [-3.2, -0.3]; p = 0.016) and at 15 month follow-up (adjusted mean difference = -2.3 mmHg; 95% CI = [-4.2, -0.39]; p = 0.0225) compared to the lower engagement group. CONCLUSION: This intervention, tested and delivered in a real-world setting, provides an example of how CHW integration into an expanded chronic care model can improve blood pressure outcomes for individuals with co-morbidities.

Patterns of multiple chronic conditions in pregnancy: Population-based study using latent class analysis.

BACKGROUND: Adults with multiple chronic conditions (MCC) are a heterogeneous population with elevated risk of future adverse health outcomes. Yet, despite the increasing prevalence of MCC globally, data about MCC in pregnancy are scarce. OBJECTIVES: To estimate the population prevalence of MCC in pregnancy and determine whether certain types of chronic conditions cluster together among pregnant women with MCC. METHODS: We conducted a population-based cohort study in Ontario, Canada, of all 15-55-year-old women with a recognised pregnancy, from 2007 to 2020. MCC was assessed from a list of 22 conditions, identified using validated algorithms. We estimated the prevalence of MCC. Next, we used latent class analysis to identify classes of co-occurring chronic conditions in women with MCC, with model selection based on parsimony, clinical interpretability and statistical fit. RESULTS: Among 2,014,508 pregnancies, 324,735 had MCC (161.2 per 1000, 95% confidence interval [CI] 160.6, 161.8). Latent class analysis resulted in a five-class solution. In four classes, mood and anxiety disorders were prominent and clustered with one additional condition, as follows: Class 1 (22.4% of women with MCC), osteoarthritis; Class 2 (23.7%), obesity; Class 3 (15.8%), substance use disorders; and Class 4 (22.1%), asthma. In Class 5 (16.1%), four physical conditions clustered together: obesity, asthma, chronic hypertension and diabetes mellitus. CONCLUSIONS: MCC is common in pregnancy, with sub-types dominated by co-occurring mental and physical health conditions. These data show the importance of preconception and perinatal interventions, particularly integrated care strategies, to optimise treatment and stabilisation of chronic conditions in women with MCC.

Predictors of basic and instrumental activities of daily living among older adults with multiple chronic conditions.

BACKGROUND: Understanding the predictors of functional status can be useful for improving modifiable predictors or identifying at-risk populations. Researchers have examined the predictors of functional status in older adults, but there has not been sufficient study in this field in older adults with multiple chronic conditions, especially in Iran. Consequently, the results of this body of research may not be generalizable to Iran. Therefore, this study was conducted to determine the predictors of functional status in Iranian older adults with multiple chronic conditions. METHODS: In this cross-sectional study, 118 Iranian older adults with multiple chronic conditions were recruited from December 2022 to September 2023. They were invited to respond to questionnaires inquiring about their demographic and health information, basic activities of daily living (BADL) and instrumental activities of daily living (IADL), depression and cognitive status. The predictors included age, gender, marital status, education, number of chronic conditions, and depression. Descriptive and analytical statistical tests (univariate and multiple regression analysis) were used to analyze the data. RESULTS: The majority of participants were married (63.9%) and women (59.3%). Based on the results of the multiple regression analysis, age (B=-0.04, P = 0.04), depression (B=-0.12, P = 0.04), and IADL (B = 0.46, P < 0.001) were significant predictors for functional status in terms of BADL. Also, marital status (B=-0.51, P = 0.05), numbers of chronic conditions (B=-0.61, P = 0.002), and BADL (B = 0.46, P < 0.001) were significant predictors for functional status in terms of IADL. CONCLUSION: The findings support the predictive ability of age, marital status, number of chronic diseases, and depression for the functional status. Older adults with multiple chronic conditions who are older, single, depressed and with more chronic conditions number are more likely to have limitations in functional status. Therefore, nurses and other health care providers can benefit from the results of this study and identify and pay more attention to the high risk older adult population.

Multimorbidity and associated informal care receiving characteristics for US older adults: a latent class analysis.

BACKGROUND: Older adults with varying patterns of multimorbidity may require distinct types of care and rely on informal caregiving to meet their care needs. This study aims to identify groups of older adults with distinct, empirically-determined multimorbidity patterns and compare characteristics of informal care received among estimated classes. METHODS: Data are from the 2011 National Health and Aging Trends Study (NHATS). Ten chronic conditions were included to estimate multimorbidity patterns among 7532 individuals using latent class analysis. Multinomial logistic regression model was estimated to examine the association between sociodemographic characteristics, health status and lifestyle variables, care-receiving characteristics and latent class membership. RESULTS: A four-class solution identified the following multimorbidity groups: some somatic conditions with moderate cognitive impairment (30%), cardiometabolic (25%), musculoskeletal (24%), and multisystem (21%). Compared with those who reported receiving no help, care recipients who received help with household activities only (OR = 1.44, 95% CI 1.05-1.98), mobility but not self-care (OR = 1.63, 95% CI 1.05-2.53), or self-care but not mobility (OR = 2.07, 95% CI 1.29-3.31) had greater likelihood of being in the multisystem group versus the some-somatic group. Having more caregivers was associated with higher odds of being in the multisystem group compared with the some-somatic group (OR = 1.09, 95% CI 1.00-1.18), whereas receiving help from paid helpers was associated with lower odds of being in the multisystem group (OR = 0.36, 95% CI 0.19-0.77). CONCLUSIONS: Results highlighted different care needs among persons with distinct combinations of multimorbidity, in particular the wide range of informal needs among older adults with multisystem multimorbidity. Policies and interventions should recognize the differential care needs associated with multimorbidity patterns to better provide person-centered care.

Multimorbidity clusters in adults 50 years or older with and without a history of cancer: National Health Interview Survey, 2018.

BACKGROUND: Multimorbidity is increasing among adults in the United States. Yet limited research has examined multimorbidity clusters in persons aged 50 years and older with and without a history of cancer. An increased understanding of multimorbidity clusters may improve the cancer survivorship experience for survivors with multimorbidity. METHODS: We identified 7580 adults aged 50 years and older with 2 or more diseases-including 811 adults with a history of primary breast, colorectal, cervical, prostate, or lung cancer-from the 2018 National Health Interview Survey. Exploratory factor analysis identified clusters of multimorbidity among cancer survivors and individuals without a history of cancer (controls). Frequency tables and chi-square tests were performed to determine overall differences in sociodemographic characteristics, health-related characteristics, and multimorbidity between groups. RESULTS: Cancer survivors reported a higher prevalence of having 4 or more diseases compared to controls (57% and 38%, respectively). Our analysis identified 6 clusters for cancer survivors and 4 clusters for controls. Three clusters (pulmonary, cardiac, and liver) included the same diseases for cancer survivors and controls. CONCLUSIONS: Diseases clustered differently across adults ≥ 50 years of age with and without a history of cancer. Findings from this study may be used to inform clinical care, increase the development and dissemination of multilevel public health interventions, escalate system improvements, and initiate innovative policy reform.

Cross-cultural adaptation and validation of the caregiver self-efficacy in contributing to patient self-care scale in China.

BACKGROUND: Caregiver self-efficacy is crucial in improving patient outcomes and caregiver well-being, but there is a lack of suitable scales to assess this concept within the context of Chinese culture. This study aimed to cross-culturally translate the Caregiver Self-Efficacy in Contributing to Patient Self-Care (CSE-CSC) Scale and evaluate its psychometric properties using classical test theory and item response theory. METHODS: The CSE-CSC scale was adapted using Brislin's translation model after obtaining authorization from the original author. A multicenter, cross-sectional study was conducted to assess the psychometric properties of this scale. Classical test theory was used to evaluate reliability (internal consistency, test-retest reliability), validity (content validity, structural validity, convergent validity), and floor and ceiling effects. Item response theory was employed to assess the fit of the rating scale model, reliability, item difficulties, and measurement invariance. RESULTS: The translation and cultural adaptation process was completed. Classical test theory demonstrated good internal consistency (Cronbach's α = 0.935) and test-retest reliability (ICC from 0.784 to 0.829, p<0.001). The I-CVI and K* of each item ranged from 0.875 to 1.00 and 0.871 to 1.00. The first-order 2-factor model fit well (χ2/df = 3.71, RMSEA = 0.082, SRMR = 0.032, CFI = 0.973, TLI = 0.60). Convergent validity showed that the CSE-CSC scores had a strong positive correlation with three separate scales of the CC-SC-CII. There was no floor and ceiling effect in this scale. Rasch analysis showed that the CSE-CSC scale demonstrated a good fit to the rating scale model and exhibited excellent reliability (person/item separation index>2, person/item reliability coefficients>0.8). The Wright map showed that item difficulty matched the respondents' measured abilities. The analysis of differential item functioning (DIF) showed that all items were comparable in gender. CONCLUSIONS: This study indicated that the CSE-CSC scale had good reliability, validity, difficulty degree, and measurement invariance. The CSE-CSC scale can be used to measure caregiver self-efficacy of Chinese patients with multiple chronic conditions.

Use of an electronic wellness instrument in the integrated health and social care of older adults: a group concept mapping study.

BACKGROUND: Health system fragmentation directly contributes to poor health and social outcomes for older adults with multiple chronic conditions and their care partners. Older adults often require support from primary care, multiple specialists, home care, community support services, and other health-care sectors and communication between these providers is unstructured and not standardized. Integrated and interprofessional team-based models of care are a recommended strategy to improve health service delivery to older adults with complex needs. Standardized assessment instruments deployed on digital platforms are considered a necessary component of integrated care. The aim of this study was to develop strategies to leverage an electronic wellness instrument, interRAI Check Up Self Report, to support integrated health and social care for older adults and their care partners in a community in Southern Ontario, Canada. METHODS: Group concept mapping, a participatory mixed-methods approach, was conducted. Participants included older adults, care partners, and representatives from: home care, community support services, specialized geriatric services, primary care, and health informatics. In a series of virtual meetings, participants generated ideas to implement the interRAI Check Up and rated the relative importance of these ideas. Hierarchical cluster analysis was used to map the ideas into clusters of similar statements. Participants reviewed the map to co-create an action plan. RESULTS: Forty-one participants contributed to a cluster map of ten action areas (e.g., engagement of older adults and care partners, instrument's ease of use, accessibility of the assessment process, person-centred process, training and education for providers, provider coordination, health information integration, health system decision support and quality improvement, and privacy and confidentiality). The health system decision support cluster was rated as the lowest relative importance and the health information integration was cluster rated as the highest relative importance. CONCLUSIONS: Many person-, provider-, and system-level factors need to be considered when implementing and using an electronic wellness instrument across health- and social-care providers. These factors are highly relevant to the integration of other standardized instruments into interprofessional team care to ensure a compassionate care approach as technology is introduced.

Multimorbidity and frailty are associated with poorer SARS-CoV-2-related outcomes: systematic review of population-based studies.

BACKGROUND: Estimating the risks and impacts of COVID-19 for different health groups at the population level is essential for orienting public health measures. Adopting a population-based approach, we conducted a systematic review to explore: (1) the etiological role of multimorbidity and frailty in developing SARS-CoV-2 infection and COVID-19-related short-term outcomes; and (2) the prognostic role of multimorbidity and frailty in developing short- and long-term outcomes. This review presents the state of the evidence in the early years of the pandemic. It was conducted within the European Union Horizon 2020 program (No: 101018317); Prospero registration: CRD42021249444. METHODS: PubMed, Embase, World Health Organisation COVID-19 Global literature on coronavirus disease, and PsycINFO were searched between January 2020 and 7 April 2021 for multimorbidity and 1 February 2022 for frailty. Quantitative peer-reviewed studies published in English with population-representative samples and validated multimorbidity and frailty tools were considered. RESULTS: Overall, 9,701 records were screened by title/abstract and 267 with full text. Finally, 14 studies were retained for multimorbidity (etiological role, n = 2; prognostic, n = 13) and 5 for frailty (etiological role, n = 2; prognostic, n = 4). Only short-term outcomes, mainly mortality, were identified. An elevated likelihood of poorer outcomes was associated with an increasing number of diseases, a higher Charlson Comorbidity Index, different disease combinations, and an increasing frailty level. DISCUSSION: Future studies, which include the effects of recent virus variants, repeated exposure and vaccination, will be useful for comparing the possible evolution of the associations observed in the earlier waves.

Correlation between Charlson comorbidity index and surgical prognosis in elderly patients with femoral neck fractures: a retrospective study.

OBJECTIVE: Femoral neck fractures (FNF) are known to have significant morbidity and mortality rates. Multiple chronic conditions (MCC) are defined as the presence of two or more chronic diseases that greatly affect the quality of life in older adults. The aim of this study is to explore the impact of MCC and Charlson comorbidity index (CCI) on surgical outcomes in patients with FNF. METHODS: Patients with FNF who underwent joint replacement surgery were selected for this study. Patients who had two or more diseases simultaneously were divided into two groups: the MCC group and the non-MCC (NMCC) group. The CCI was calculated to assess the severity of patients' comorbidities in the MCC group. Baseline data, surgical details, and prognosis-related indicators were analyzed and compared between the two patient groups. Spearman correlation analysis was performed to assess the relationship between CCI and length of hospital stay, Harris score, skeletal muscle index (SMI), and age. Univariate and multivariate logistic regression analysis was conducted to identify the risk factors for mortality in FNF patients at 1 and 5 years after surgery. RESULTS: A total of 103 patients were included in the MCC group, while the NMCC group consisted of 40 patients. However, the patients in the MCC group were found to be older, had a higher incidence of sarcopenia, and lower SMI values (p < 0.001). Patients in the MCC group had longer hospitalization times, lower Harris scores, higher intensive care unit (ICU) admission rates, and higher complication rates (p = 0.045, p = 0.035, p = 0.019, p = 0.010). Spearman correlation analysis revealed that CCI was positively correlated with hospitalization and age (p < 0.001, p < 0.001), while it was negatively correlated with Harris score and SMI value (p < 0.001, p < 0.001). Univariate and multivariate logistic regression analysis demonstrated that MCC patients had higher 1-year and 5-year mortality rates. Hospitalization time was identified as a risk factor for death in FNF patients 1 year after joint replacement (p < 0.001), whereas CCI and age were identified as risk factors for death 5 years after surgery (p < 0.001, p < 0.001). Kaplan-Meier survival analysis results showed that the difference in death time between the two groups of patients with MCC and NMCC was statistically significant (p < 0.001). Cox proportional hazard model analysis showed that CCI, age and SMI were risk factors affecting patient death. CONCLUSION: The surgical prognosis of patients with MCC, CCI and FNF is related. The higher the CCI, the worse the patient's function and the higher the long-term risk of death.

Perceived stress, positive psychological capital and health literacy in patients with multiple chronic conditions: A structural equation modelling.

AIM: To investigate the structural relationships among perceived stress (PS), positive psychological capital (PsyCap) and health literacy (HL) in patients with multiple chronic conditions (MCC) and construct a model to explore the relationships of PS and PsyCap on HL. BACKGROUND: HL is critical in the rehabilitation and management of patients with MCC. Extensive understanding of the relationships between research variables can help nursing staff to implement effective programmes that improve the level of HL of patients. However, currently there is no research that has evaluated the structural relationships among these variables using a single model. METHODS: This study adhered to the STROBE guidelines for reporting cross-sectional studies. The Health Literacy Scale for Chronic Patients, Chinese Perceived Stress Scale (CPSS) and Positive Psychological Capital Questionnaire were used to assess HL, PS and PsyCap, respectively. Questionnaires were distributed to 317 patients with MCC attending a tertiary general care hospital in China from February to May 2023, using convenience sampling approach. Structural equation modelling was used to validate the proposed model. RESULTS: The findings showed that PS has a negative relationship with HL and PsyCap. PS was indirectly associated with HL through PsyCap. The results indicated that PsyCap was positively associated with HL. The PS and PsyCap explained 64% of the variance in HL. CONCLUSIONS: The findings showed that the proposed model had high validity and structural relationships between chosen variables were observed for MCC patients. RELEVANCE TO CLINICAL PRACTICE: These results may help nursing staff develop strategies to improve the HL of patients with MCC, which should focus on reducing PS and enhancing PsyCap to improve HL. Nursing staff can provide targeted psychological counselling and health guidance for patients to alleviate negative emotions and further promote their HL. PATIENT OR PUBLIC CONTRIBUTION: Participate in research and fill out questionnaires.

Self-identified culturally related stressors that influence self-care in older adults with multiple chronic conditions: A qualitative study.

AIM: To identify culturally related stressors that influence self-care in Chinese older adults with multiple chronic conditions. BACKGROUND: Effective self-care can improve health outcomes for chronic conditions, but implementing self-care is challenging. Individuals with multiple chronic conditions face even more self-care complexity than those with single chronic conditions, generating additional stressors. Although stressors have been found to negatively influence self-care in multiple chronic conditions, the role of culture in generating stressors has been neglected. DESIGN: This paper reports on the qualitative component of a larger mixed-methods study. Two free-response items in a survey were used to identify culturally related stressors that influence self-care. This report adhered to the SRQR guideline checklist. METHODS: Data were collected between January and April 2022. One hundred and thirty-eight free text responses asking participants to identify stressors that influenced their self-care effectiveness were analysed sequentially using deductive content analysis and thematic analysis. RESULTS: Findings from deductive content analysis largely confirmed published work in Western literature on stressors complicating self-care, including symptom burdens, financial strains, social disconnection, caregiving responsibilities and major life events. Findings from reflexive thematic analysis extended current literature by identifying three culturally relevant stressors: intergenerational obligations and commitments, ambivalence about receiving care and worries about potential problems. CONCLUSION: Chinese older adults with multiple chronic conditions identified a wide range of stressors that impacted their day-to-day self-care. This study provided valuable insights into culturally related stressors in older adults with multiple chronic conditions. Findings deepened our knowledge of cultural influences on the success of self-care in older adults with multiple chronic conditions, suggesting the potential for reaching populations across different cultures and regions. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: Stressors that might influence self-care ability are important for nurses to assess in people with multiple chronic conditions. The design of self-care interventions should take a culturally tailored intergenerational family-centred approach to help mitigate the impact of stressors and ultimately improve patient outcomes. IMPACT: What problem did the study address? Stressors documented in older adults with MCCs have all been generated from research with Western populations. China is now home to the largest population of older people in the world. Understanding the influence of culturally relevant stressors on self-care in Chinese older adults with MCCs is lacking. What were the main findings? Findings from deductive content analysis largely confirmed published work in Western literature on stressors that complicated self-care, including symptom burdens, financial strains, social disconnection, caregiving responsibilities and major life events. Findings from reflexive thematic analysis extended current literature by identifying three culturally relevant stressors in older adults with MCCs in China: intergenerational obligations and commitments, ambivalence about receiving care and worries about potential problems. Where and on whom will the research have an impact? The research will have an impact on guiding nurses' assessment of culturally relevant stressors' impact on self-care for older adults with MCCs. In addition, findings could inform research and policy development to aim at mitigating the impact of culturally based stressors on self-care. REPORTING METHOD: This study adhered to the Standards for Reporting Qualitative Research (SRQR) guideline checklist. PATIENT OR PUBLIC CONTRIBUTION: During the member-checking process, the validation of findings for accuracy was carried out by 10 participants, who also found resonance between these findings and their own experiences.

Transitional care model for older adults with multiple chronic conditions: An evaluation of benefits utilising an umbrella review.

AIMS: To synthesise and describe the combined evidence from systematic reviews of interventions using elements from the Transitional Care Model, on the content and timeframe of the interventions and the related improvement of outcomes for older patients with multiple chronic conditions. BACKGROUND: The population of older patients with multiple chronic conditions is increasing worldwide and trajectories are often complicated by risk factors. The Transitional Care Model may contain elements to support transitions between hospital and home. DESIGN: An umbrella review. REVIEW METHODS: A comprehensive search in five electronic databases was performed in April 2021 based on the search terms: 'Patients ≥60 years,' 'multi-morbidity,' 'Transitional care model,' 'Transitional care,' and 'Systematic review.' PRISMA guidelines was used. RESULTS: Five systematic reviews published from 2011 to 2020 comprising 62 intervention studies (59 randomised controlled trials and three quasi-experimental trials) were included in the review. The synthesis predominantly revealed significant improvements in decreasing re-admissions and financial costs and increasing patients' quality of life and satisfaction during discharge. CONCLUSION: The results of the review indicate that multiple elements from the Transitional Care Model have achieved significant improvements in older patients' transitions from hospital to home. Especially a combination of coordination, communication, collaboration and continuity of care in transitions, organised information and education for patients and pre-arranged structured post-discharge follow-ups. IMPACT: The transition from hospital to home is a complex process for older patients with multiple chronic conditions. A specific focus on coordination, continuity, and patient education should be implemented in the discharge process. Nurses with specialised knowledge in transitional care are needed to ensure safe transitions. PATIENT AND PUBLIC CONTRIBUTION: The umbrella review is part of a larger research program which involved a patient expert advisory board, which participated in discussing the relevance of the elements within the umbrella review.

Healthcare service use for children with chronic complex diseases: A longitudinal six-year follow-up study.

PURPOSE: The objective was analysed the patterns use of healthcare services of this population and the influence of their clinical and sociodemographic characteristics. DESIGN AND METHODS: A six-year longitudinal follow-up study was performed to evaluate the annual healthcare resources use and clinical data among children with complex chronic diseases in Spain between 2015 and 2021. The sample trends in healthcare usage and the associated factors were analysed using ANCOVA and multivariable linear regression models. RESULTS: Patients had high attendance during the follow-up period, with >15 episodes year. This trend decreased over time, especially in children with oncological diseases compared with other diseases (F (16.75; 825.4) = 32.457; p < 0.001). A multivariable model showed that children with a greater number of comorbidities (ß = 0.17), shorter survival time (ß = -0.23), who had contact with the palliative care unit (ß = 0.16), and whose mothers had a higher professional occupation (ß = 0.14), had a greater use of the healthcare system. CONCLUSIONS: Children with a higher number of comorbidities and the use of medical devices made a greater frequentation of health services, showing a trend of decreasing use over time. Socioeconomic factors such as mothers' occupational status determine healthcare frequentation. These results suggest the existence of persistent gaps in care coordination sustained over time. PRACTICAL IMPLICATIONS: Systematized and coordinated models of care for this population should consider the presence of inequalities in health care use.

The Intersection of Geriatrics, Climate Change, and Wilderness Medicine: Education is Critical.

According to the US Census, for the first time in history, older adults are projected to exceed the number of children by 2035. These seniors are headed to the outdoors in increasing numbers and face unique risks. They benefit from careful pre-event evaluation planning to maintain their health in wilderness environments. Climate change is affecting all of us, but seniors are considered an especially vulnerable group. This vulnerability needs to be addressed not only when older adults head into the wilderness but also when the wilderness "comes to them" in areas where wilderness medicine and disaster medicine overlap. Education of both providers and patients is vital. This article aims to discuss the special needs of older adults/seniors /elders (defined as those over 65 unless otherwise indicated) in the wilderness as well as the vulnerability of older adults to climate change, both during planned wilderness activities and when the wilderness "comes to them" because of climate change, and to identify opportunities for education and adaptation of patients and education of physicians and wilderness and disaster responders to care for these older patients. The PubMed and Google Scholar Database search engines were utilized to review relevant English language publications between 2000 and 2023 that addressed individuals over 65 and explored the overlap of geriatrics (aged over 65), wilderness and disaster medicine, and climate change and create a perspective summary. Because of increased numbers of older adults heading into the wilderness for outdoor activities or having wilderness thrust upon them due to climate change, cross training of all specialties including the fields of emergency, geriatrics, wilderness medicine, and disaster medicine is needed in collaboration with other organizations and search and rescue. Response agencies must recognize that training in wilderness medicine provides a background for practitioners working in dangerous and remote settings and ought to seek out individuals with such skills when placing responders in the field. Climate change is making these intersections and the need for this education more urgent with time.

Integration of palliative care in the management of multiple chronic conditions: An expert consensus paper with policy implications.

BACKGROUND: This paper was jointly developed from members of the American Academy of Nursing Expert Panels on Palliative and End of Life Care, Primary Care, Aging, Acute and Critical Care, and two expert physicians. PURPOSE: The overarching goal is to promote the integration of palliative care as symptom management into the primary care setting to transform care for patients living with multiple chronic conditions. METHODS: Embracing the recommendations made by the World Health Organization, the U.S. Department of Health and Human Services, and the National Academies of Science Engineering and Medicine to initiate palliative care or symptom management at the onset of nonreversible or serious chronic conditions. DISCUSSION: Earlier palliative interventions reduce disease exacerbation, prevent hospitalization, maintain physical functioning, and support health-related quality of life. CONCLUSION: This is a needed paradigm shift as the nation's aging population escalates, Americans are living longer, and the healthcare costs for the nation are unprecedented.

Temporal trends and correlates in multiple hospitalizations among older adults: findings from a nationally representative sample in China.

OBJECTIVE: This study aims to examine the trends and correlates in multiple hospitalizations among older adults in China. METHODS: The data were from the China Health and Retirement Longitudinal Study (CHARLS), and generalized ordered logit model (GOLM) was used to identify the correlates of multiple hospitalizations among older adults aged≥60 years old. RESULTS: Between 2011 and 2018, the proportion of older adults having multiple hospitalizations in the past year showed an increasing trend in the total sample (p value for trend = 0.014). Being older, male, illiterate, living in the middle/western region, having higher annual per capita household expenditure, health insurance, multimorbidity, and being depressed were associated with increased odds of multiple hospitalizations. CONCLUSIONS: Our findings indicated that older adults with multiple hospitalizations may expect an increasing burden on healthcare system. More efforts are needed to improve health insurance and primary healthcare to reduce avoidable hospitalizations.

Network analysis of the urban-rural differences in depressive symptoms among older adults with multiple chronic conditions: Evidence from a national survey.

BACKGROUND: Evidence on the differences in depressive symptoms among older adults with multiple chronic conditions (MCCs) in urban and rural areas is limited. METHODS: Measures of depressive symptoms (Center for Epidemiologic Studies Depression Scale-10) and demographic factors (age, gender, and urban-rural distribution) were used. RESULTS: A total of 4021 older adults with MCCs were included in this study. Significant differences were observed in both network global strength (Urban: 3.989 vs. Rural: 3.703, S = 0.286, p = 0.003) and network structure (M = 0.139, p = 0.002) between urban and rural residents. CONCLUSIONS: The study highlights the need for region-specific approaches to understanding and addressing depression and holds the potential to enhance understanding of the psychological health status of older adults with MCCs in urban and rural settings.

Predictive model for the risk of paediatric intensive care utilization in children with medical complexity: A longitudinal retrospective cohort study.

BACKGROUND: Children with medical complexity (CMC) are at increased risk of admission in intensive care. Despite improvements in mortality rates, there remains a burden of morbidity, long-term health care needs and hospital readmissions. Beyond clinical factors, socio-demographic determinants could impact utilization of acute services. AIM: To identify risk factors that can differentiate CMC who are admitted to the paediatric intensive care unit (PICU). STUDY DESIGN: A 6-year longitudinal retrospective cohort study evaluated clinical, socio-demographic and health care utilization. RESULTS: A total of 248 CMC were included, with a median age of 13 years (9.75-17.00). Intensive care admission rate was 47.2%. The risk of PICU admission was higher for children undergoing surgical interventions (HR = 1.58, 95% CI 1.34-1.86, p < .001) and those using medical devices (HR = 1.81, 95% CI 1.54-2.13, p < .001). Mother's higher educational level was a protective factor (HR = 0.66, 95% CI 0.55-0.79, p < .001). Multivariable analysis revealed significant associations between risk of admission and the presence of malignancy, comorbidities, home medical devices, surgical procedures and higher health care utilization. Children's age and higher maternal educational level acted as protective factors. CONCLUSION: Socio-demographic factors should be considered in the provision of care to CMC. Individualized assessments to guide supportive interventions adapted to socio-economic factors may prevent PICU admissions. RELEVANCE TO CLINICAL PRACTICE: This study highlights the importance of integrating individualized assessments of socio-demographic risk factors, such as maternal educational level, into the clinical practice of paediatric nurses. Moreover, targeted interventions, including educational resources and community support programmes, may optimize care.

A quality improvement evaluation of a standardized intervention for children with medical complexity transitioning to adult care.

Children with medical complexity have medical fragility, chronic disease, technology dependence, and high healthcare use. Their transition to adult health care at age 18 involves medical and social elements and follows no standardized process. Our goal was to improve transition readiness in children with medical complexity using a transition intervention within a Complex Care program. All children with medical complexity aged 14 to 18 were included in this quality improvement (QI) project (n = 54). We conducted a pre- and post-intervention chart review to assess transition outcomes and implemented a transition intervention for 6 months, which included an age-stratified checklist, charting template, and transition rounds. Before the intervention, 72% of 17- to 18-year-old patients had documented transition discussions, which increased to 86%. Patients with a family physician increased as well (61% to 73% for 17- to 18-year-olds). Three transition education rounds were held. The intervention increased transition readiness, provided tools to facilitate transition, and created a forum for conversation.