Individual and joint exposure to air pollutants and patterns of multiple chronic conditions.

Existing research on the detrimental effects of air pollution and its mixture on multiple chronic conditions (MCC) is not yet fully recognized. Our objective was to examine if individual and joint exposure to air pollution is associated with the incidence and patterns of MCC. Totally 10,231 CHARLS 2015 participants aged over 45 years and 1,938 without MCC were followed up in 2018 and 2020. Residential-levelcumulative personal exposure concentrations of PM1, PM10, PM2.5, CO, O3, NO2, SO2, NO3-, Cl-, NH4+, and SO42- at the residential level were determined utilizing a spatio-temporal random forest model with a spatial resolution of 0.1° × 0.1°. In the cross-sectional and longitudinal research, logistic regression, cox regression analysis, and quantile g-computation were utilized to estimate the single and joint effect with MCC and its patterns, respectively. Interaction analyses and stratified analyses were also performed. A correlation was observed between the prevalence of cardiovascular illnesses and the presence of all 11 major air pollutants. PM2.5, PM10, NH4+, NO3-, CO, and SO42- are associated with an increased frequency of respiratory disorders. An increase of PM2.5, PM1, PM10, NO2, and SO2 (a 10 µg/m3 rise), CO (a 0.1 mg/m3 rise), and PMCs (Cl-, NH4+, NO3-, and SO42-) (a 1 µg/m3 rise) corresponded to the HRs (95% CI) for developing MCC of 1.194 (95% CI: 1.043, 1.367), 1.362 (95% CI: 1.073, 1.728), 1.115 (95% CI: 1.026, 1.212), 1.443 (95% CI: 1.151, 1.808), 3.175 (95% CI: 2.291, 4.401), 1.272 (95% CI: 1.149,1.410), 1.382 (95% CI: 1.011, 1.888), 1.107 (95% CI: 1.003, 1.222), 1.035 (95% CI: 0.984, 1.088), and 1.122 (95% CI: 1.086, 1.160), respectively. SO2 was the predominant contributor to the combined effect (HR: 2.083, 95% CI: 1.659-2.508). Gender, age, drinking, and health status could modify the effects of air pollutants on MCC patterns. Long-term exposure to air pollution is correlated to the incidence and patterns of MCC in middle-aged and elderly Chinese individuals. Preventive methods are essential to safeguarding those susceptible to MCC.

The Impact of Multimorbidity on Labor Force Participation Among the Middle-Aged and Older Working Population in the United States.

OBJECTIVES: Multimorbidity, known as multiple chronic conditions (MCC), is the coexistence of two or more chronic health conditions (CHC). The near-retirement-age population with MCC is more likely to experience discontinued labor force participation (LFP). Our objective was to evaluate the impact of MCC on LFP among adults aged 50-64 and to explore heterogeneous effects between self-employed and non-self-employed workers. METHODS: We constructed our sample using the Health and Retirement Study (HRS) from 1996 to 2018. We adopted an individual fixed-effect (F.E.) model and propensity score matching (PSM) to measure the impact of MCC on the probability of being employed and changes in annual work hours. RESULTS: 50.5% of respondents have MCC. Individuals with MCC exhibit a predicted probability of being employed that is 9.3 percentage points (p < .01, 95% confidence interval [95% CI]: -0.109, -0.078) lower than those without MCC. Compared with non-CHC, MCC significantly reduced annual working hours by 6.1% (p < .01, 95% CI: -0.091, -0.036) in the F.E. model and by 4.9% (p < .01, 95% CI: -0.064, -0.033) in PSM estimation. The effect is more pronounced for the self-employed with MCC, who have 13.0% (p < .05, 95% CI: -0.233, -0.026) fewer annual work hours than non-CHC based on the FE model and 13.4% (p < .01, 95% CI: -0.197, -0.070) in PSM estimation. DISCUSSION: MCC significantly reduces LFP compared with non-MCC. MCC has a heterogeneous impact across occupational types. It is important to support the near-retirement-age working population with multimorbidity through effective clinical interventions and workplace wellness policies to help manage health conditions and remain active in the labor market.

Descriptive Epidemiology of New York City Older Adult Patients With Multiple Chronic Conditions.

We characterized comorbidity profiles and cardiometabolic risk factors among older adults with multiple chronic conditions (MCCs) in New York City using an intersectionality approach. Electronic health record data were obtained from the INSIGHT Clinical Research Network on 367,901 New York City residents aged 50 years or older with MCCs. Comorbidity profiles were heterogeneous. The most common profile across sex and racial and ethnic groups was co-occurring hypertension and hyperlipidemia; prevalence of these 2 conditions differed across groups (4.7%-7.3% co-occurrence alone, 65.1%-88.0% with other conditions). Significant sex and racial and ethnic differences were observed, which may reflect accumulated disparities in risk factors and health care access across the life course.

Use of chronic care management service among Medicare beneficiaries in 2015-2019.

BACKGROUND: The Centers for Medicare and Medicaid Services (CMS) introduced chronic care management (CCM) services in 2015 for patients with multiple chronic diseases. Few studies examine the utilization of CCM services by geographic region, sociodemographic, and clinical characteristics. METHODS: We used 2014-2019 Medicare claims data from a 5% random sample of fee-for-service beneficiaries aged 65 years or over. We included beneficiaries potentially eligible for CCM services because they had multiple chronic conditions (1,073,729 in 2015 and 1,130,523 in 2019). We calculated the proportion of potentially eligible beneficiaries receiving CCM service each year for the total population and by geographic region, sociodemographic, and clinical characteristics. RESULTS: The proportion of beneficiaries with two or more chronic conditions receiving CCM services increased from 1.1% in 2015 to 3.4% in 2019. The increase in CCM use was higher in the southern region, among dually eligible beneficiaries and beneficiaries with a greater burden of chronic conditions (2-5 conditions vs ≥10 conditions: 0.7% vs 2.0% in 2015; 2.1% vs 7.0% in 2019) and frailty (robust vs severely frail: 0.6% vs 3.3% in 2015; 1.9% vs 9.4% in 2019). Nearly one out of five recipients did not continue CCM service after the initial service. CONCLUSION: We found that CCM service is being used by a very small fraction of eligible patients. Barriers and facilitators to more effective CCM adoption should be identified and incorporated into strategies that encourage more widespread use of this Medicare benefit.

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.

Acute Care Use Among Patients With Multiple Chronic Conditions Receiving Care From Nurse Practitioner Practices in Health Professional Shortage Areas.

BACKGROUND: Patients with multiple chronic conditions often have many care plans, polypharmacy, and unrelieved symptoms that contribute to high emergency department and hospital use. High-quality primary care delivered in practices that employ nurse practitioners can help prevent the need for such acute care services. However, such practices located in primary care health professional shortage areas face challenges caring for these patients because of higher workloads and fewer resources. OBJECTIVE: We examined differences in hospitalization and emergency department use among patients with multiple chronic conditions who receive care from practices that employ nurse practitioners in health professional shortage areas compared to practices that employ nurse practitioners in non-health professional shortage areas. METHODS: We performed an analysis of Medicare claims, merged with Health Resources and Services Administration data on health professional shortage area status in five states. Our sample included 394,424 community-dwelling Medicare beneficiaries aged ≥65 years, with at least two of 15 common chronic conditions who received care in 779 practices that employ nurse practitioners. We used logistic regression to assess the relationship between health professional shortage area status and emergency department visits or hospitalizations. RESULTS: We found a higher likelihood of emergency department visits among patients in health professional shortage areas compared to those in non-health professional shortage areas and no difference in the likelihood of hospitalization. DISCUSSION: Emergency department use differences exist among older adults with multiple chronic conditions receiving care in practices that employ nurse practitioners in health professional shortage areas, compared to those in non-health professional shortage areas. To address this disparity, the health professional shortage area program should invest in recruiting and retaining nurse practitioners to health professional shortage areas to ease workforce shortages.

Living on low-incomes with multiple long-term health conditions: A new method to explore the complex interaction between finance and health.

People on low-incomes in the UK develop multiple long-term health conditions over 10 years earlier than affluent individuals. Financial diaries -new to public health- are used to explore the lived experiences of financially-vulnerable individuals, diagnosed with at least one long-term condition, living in two inner-city London Boroughs. Findings show that the health status of these individuals is a key barrier to work opportunities, undermining their income. Their precarious and uncertain financial situation, sometimes combined with housing issues, increased stress and anxiety which, in turn, contributed to further deteriorate participants' health. Long-term health conditions limited the strategies to overcome moments of financial crisis and diarists frequently used credit to cope. Restrictions to access reliable services and timely support were connected to the progression of multiple long-term conditions. Models that integrate healthcare, public health, welfare and financial support are needed to slow down the progression from one to many long-term health conditions.

Service innovations for people with multiple long-term conditions: reflections of a rapid evaluation team.

Background: People living with multiple long-term conditions represent a significant concern for National Health Service policy and practice, and their care is a major theme in the 2019 National Health Service Long Term Plan. The Birmingham RAND and Cambridge Rapid Evaluation Centre team has undertaken a thematic synthesis of the 10 evaluations it has conducted from 2018 to 2023, exploring the needs, priorities and implications for people with multiple long-term conditions. Objectives: The aims for this overarching study were to: (1) build a body of learning about service innovations in primary and community settings for people of all ages with multiple long-term conditions, focused on questions that matter most to people with multimorbidity; and (2) develop methodological insights about how rapid evaluation can be used to inform the scoping, testing and implementation of service innovations for people with multiple long-term conditions. Design: The focus on multiple long-term conditions came from a Birmingham RAND and Cambridge Rapid Evaluation Centre prioritisation process undertaken in 2018 using James Lind Alliance methods. Cross-analysis of the findings from the 10 individual rapid evaluations was supplemented by (1) building aspects of multimorbidity into the design of later evaluations; (2) interviewing national and regional stakeholders (n=19) working in or alongside integrated care systems; (3) undertaking a rapid review of evidence on remote monitoring for people with multiple long-term conditions (19 papers included); and (4) testing overall insights with organisations representing patients and carers through a patient, public and professional engagement workshop with 10 participants plus members of the research team. Results: While living with multiple long-term conditions is common and is the norm for people over the age of 50 using health and care services, it is not often a focus of health service provision or innovation, nor of research and evaluation activity. We discuss six themes emerging from the totality of the study: (1) our health system is mainly organised around single conditions and not multiple long-term conditions; (2) research calls and studies usually focus on single conditions and associated services; (3) building opportunities for engaged, informed individuals and carers and improved self-management; (4) the importance of measures that matter for patients and carers; (5) barriers to developing and implementing service innovations for people with multiple long-term conditions; and (6) what is needed to make patients with multiple long-term conditions a priority in healthcare planning and delivery. Limitations: Care of people with multiple long-term conditions was not the principal focus of several of the rapid evaluations. While this was a finding in itself, it limited our learning about designing and implementing, as well as methodological approaches to evaluating, service innovations for people with multiple long-term conditions. Conclusions: Through a thematic analysis of the portfolio of evaluations, we have deduced a set of suggested implications for how the needs of people with multiple long-term conditions can be better embedded in policy, research and practice. Future work: Areas of uncertainty related to the care of people with multiple long-term conditions should be further explored, including developing and testing measures of patient experience of (un)co-ordinated care across settings, and interrogating the experience of health and care staff when working with people with multiple long-term conditions, to understand what works. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR134284) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 15. See the NIHR Funding and Awards website for further award information.

Many people in England live with two or more physical and/or mental health conditions that are expected to last for years. Estimates vary, but it is likely that a majority of National Health Service services are serving people living with two or more long-term conditions. We wanted to find out how well the needs of this group are taken into account when new types of health care are introduced, or existing services are reorganised. To do this, we went back to all 10 of the health service innovations that had been studied by our Birmingham RAND and Cambridge Evaluation Centre from 2018 to 2023. We did some extra research, including discussions with patient representatives and interviews with National Health Service policy-makers and managers at national and regional levels. We also looked at what new research had been published about one example of a new healthcare technology that is intended to help people who have several long-term health conditions: monitors that can be used by health service staff to measure patients' symptoms when they are in their own home. Our main finding was that most National Health Service attention is given to organising care for single conditions, often treating them in isolation. Patients' many treatments and needs are not routinely considered all at the same time by healthcare staff, nor by researchers. Care for one condition is too often not co-ordinated with care for other health problems that a patient may have. Although the situation of people living with several long-term health conditions is in principle understood by healthcare staff, managers and researchers, relatively little is done in practice to meet their needs. We conclude by suggesting ways that policy-makers, healthcare staff and researchers could improve how they help people living with multiple long-term conditions.

Prevalence and determinants of multiple chronic conditions (MCC) among young adults in Indian households: an analysis of NFHS-5.

BACKGROUND: Multiple chronic conditions (MCC) are defined as the presence of two or more chronic conditions, that significantly impact health status, functional capacity, quality of life, and overall healthcare management. Despite the significant evidence on chronic disease burden, the co-existence of MCC within a household in low- and middle-income countries (LMICs) is less studied. This study therefore estimates the prevalence of MCC and its determinants among adults in the Indian households. METHODS: Data used in this study were drawn from the fifth round of the National Family Health Survey (NFHS) conducted in 2019-21. Data sets of men (15-54 years) and women (15-49 years) were used for the study. The total sample size of adults for this analysis was N = 239,848. The outcome variable of this study was multiple chronic conditions (MCC) in adults which included a total of nine chronic conditions (hypertension, diabetes, chronic respiratory diseases, chronic kidney disorders, cancer, thyroid disorders, obesity, and heart diseases, consuming alcohol, chewing tobacco, and smoking) documented in NFHS-5. Descriptive statistics and binary logistic regression analysis were used to quantify the results. RESULTS: A prevalence of 5.5% of MCC in adults emerged from our study. Logistic regression analysis identified that younger age, males (AOR 0.36 (0.33-0.39)), urban areas (AOR 1.11 (1.02-1.17)) as the place of residence, and participants representing SC (AOR 0.89 (0.81-0.97)), and ST (AOR 1.30 (1.17-1.45)), had a higher risk of MCC irrespective of level of education, type of occupation, marital status, or wealth index, and states from any category of social progress. CONCLUSION: A 5% prevalence of MCC specifically obesity, substance use, and hypertension calls for integrated efforts aiming at behavior change, and regulatory efforts to prevent further increase of MCC among young adults in India.

Experiences and challenges of people living with multiple long-term conditions in managing their care in primary care settings in Kerala, India: A qualitative study.

BACKGROUND: Multimorbidity or multiple long-term conditions (MLTCs), the coexistence of two or more chronic conditions within an individual, presents a growing concern for healthcare systems and individuals' well-being. However, we know little about the experiences of those living with MLTCs in low- and middle-income countries (LMICs) such as India. We explore how people living with MLTCs describe their illness, their engagements with healthcare services, and challenges they face within primary care settings in Kerala, India. METHODS: We designed a qualitative descriptive study and conducted in-depth, semi-structured interviews with 31 people (16 males and 15 females) from family health centres (FHCs) in Kerala. Interview data were recorded, transcribed, and thematic analysis using the Framework Method was undertaken. FINDINGS: Two main themes and three sub-themes each were identified; (1) Illness impacts on life (a)physical issues (b) psychological difficulties (c) challenges of self-management and (2) Care-coordination maze (a)fragmentation and poor continuity of care (b) medication management; an uphill battle and (c) primary care falling short. All participants reported physical and psychological challenges associated with their MLTCs. Younger participants reported difficulties in their professional lives, while older participants found household activities challenging. Emotional struggles encompassed feelings of hopelessness and fear rooted in concerns about chronic illness and physical limitations. Older participants, adhering to Kerala's familial support norms, often found themselves emotionally distressed by the notion of burdening their children. Challenges in self-management, such as dietary restrictions, medication adherence, and physical activity engagement, were common. The study highlighted difficulties in coordinating care, primarily related to traveling to multiple healthcare facilities, and patients' perceptions of FHCs as fit for diabetes and hypertension management rather than their multiple conditions. Additionally, participants struggled to manage the task of remembering and consistently taking multiple medications, which was compounded by confusion and memory-related issues. CONCLUSION: This study offers an in-depth view of the experiences of individuals living with MLTCs from Kerala, India. It emphasizes the need for tailored and patient-centred approaches that enhance continuity and coordination of care to manage complex MLTCs in India and similar LMICs.