Models of care for improving health-related quality of life, mental health, or mortality in persons with multimorbidity: A systematic review of randomized controlled trials.

Objectives: To categorize and examine the effectiveness regarding health-related quality of life (HRQoL), mental health, and mortality of care models for persons with multimorbidity in primary care, community care, and hospitals through a systematic review. Methods: We searched PubMed, Embase, and Cochrane Central Register of Controlled Trials up to May 2020. One author screened titles and abstracts, and to validate, a second author screened 5% of the studies. Two authors independently extracted data and assessed risk of bias using the tool by the Cochrane Effective Practice and Organisation of Care group. Study inclusion criteria were (1) participants aged ≥ 18 years with multimorbidity; (2) referred to multimorbidity or two or more specific chronic conditions in the title or abstract; (3) randomized controlled design; and (4) HRQoL, mental health, or mortality as primary outcome measures. We used the Foundation Framework to categorize the models and the PRISMA-guideline for reporting. Results: In this study, the first to report effectiveness of care models in patients with multimorbidity in hospital settings, we included 30 studies and 9,777 participants with multimorbidity. 12 studies were located in primary care, 9 in community care, and 9 in hospitals. HRQoL was reported as the primary outcome in 12 studies, mental health in 17 studies, and mortality in three studies-with significant improvements in 5, 14, and 2, respectively. The studies are presented according to settings. Conclusions: Although 20 of the care models reported positive effects, the variations in populations, settings, model elements, and outcome measures made it difficult to conclude on which models and model elements were effective.

Catalogue of multimorbidity mean based severity and associational prevalence rates between 199+ chronic conditions-A nationwide register-based population study.

BACKGROUND: Real-world data on multimorbidity represents an important but underutilised source of evidence for the planning of healthcare services, including prevention, treatments, and health economic modelling. AIMS: This study aimed to estimate means of multimorbidity and provide associated prevalence rates and frequencies between 199 x 199 chronic conditions and disease groups based on the total adult Danish population and sex, age, and educational attainment. Thus, this study provides an off-the-shelf catalogue for use in treatments and planning by clinicians, decision-makers and researchers. METHODS: The study population contained all Danish residents above 16 years on 1 January 2013 (n = 4,555,439). The data was based on the linkage of six national registers covering hospital contacts, services in general practice, filled-in out-of-hospital prescriptions, and educational attainments. The health registers were used to identify the 199 chronic conditions based on the ICD-10 classification system. RESULTS: The mean number of chronic conditions (NCC) was 2.2. The mean increased with age, women had a higher mean than men, and there was a social gradient with the mean increasing with lower educational attainment. The mean NCC varied from 3.3-9.8 among all conditions. Across disease groups, the highest mean NCC were found within disease group N (chronic renal failure, mean = 8.8), D (in situ and benign neoplasms; mean = 6.5), K (diseases of the digestive system; mean = 5.7), and H (diseases of the eye and the ear; mean = 5.6). The highest mean NCC among the 29 common diseases was heart failure, ischemic heart diseases, angina pectoris, stroke, and dementia, with a mean above 6.5. Several prevalent conditions like hypertension, arthritis, chronic lower respiratory diseases, depression, type 2 diabetes, and overweight transcended other conditions regarding the associated prevalence rates. As one of the most frequent, hypertensive diseases were highly associated with arthritis (50.4%), depression (37.4%), type 2 diabetes (75.4%), cancers (49.7%), and being overweight (39.7%)-meaning that 50.4% of people with arthritis, 37.4% of people with depression and so on also had hypertensive diseases. The largest differences in means between individuals with no educational attainment and individuals with high educational attainment were found within disease groups J (diseases of the respiratory system, ratio = 1.8), Q (congenital malformations, deformations, and chromosomal abnormalities, ratio = 1.7), and B (viral hepatitis and human immunodeficiency virus disease, ratio = 1.7). CONCLUSIONS: The current study provides a nationwide off-the-shelf catalogue of multimorbidity means and real-world associations estimates of 199+ chronic conditions for future clinical treatments and health care systems planning. The findings described are just one example of numerous results and underline that multimorbidity is highly prevalent in the adult Danish population and that it is a vital condition transcending all future medical treatment. The data offer essential information on the multimorbidity burden of disease in future differentiated treatments, healthcare planning, and economic, aetiological, and other research.

Reaching Frail Elderly Patients to Optimize Diagnosis and Management of Atrial Fibrillation (REAFEL): A Feasibility Study of a Cross-Sectoral Shared-Care Model.

Introduction: Atrial fibrillation (AF) management in primary care often requires a referral to cardiology clinics, which can be strenuous for frail patients. We developed "cardio-share" (CS), a new cross-sector collaboration model, to ease this process. General practitioners (GPs) can use a compact Holter monitor (C3 from Cortrium) to receive remote advice from the cardiologist. Objective: To test the feasibility and acceptability of the CS model to manage suspected AF in frail elderly patients. Methods: We used a mixed methods design, including the preparation of qualitative semistructured interviews of GPs and nurses. Results: Between MAR-2019 and FEB-2020, 54 patients were consulted through the CS model, of whom 35 underwent C3 Holter monitoring. The time from referral to a final Holter report was shortened from a mean (SD) of 117 (45) days in usual care to 30 days (13) with the CS model. Furthermore, 90% of the patients did not need to attend visits at the cardiology clinic. The GPs and nurses highlighted the ease of using the C3 monitor. Their perception was that patients were confident in the GPs' collaboration with cardiologists. Conclusions: The CS model using a C3 monitor for AF is both feasible and seems acceptable to GPs. The elapsed time from referral to the Holter report performed for the diagnosis was significantly reduced.

Why do general practitioners not refer patients to behaviour-change programmes after preventive health checks? A mixed-method study.

BACKGROUND: This study was embedded in the Check-In randomised controlled trial that investigated the effectiveness of general practice-based preventive health checks on adverse health behaviour and early detection of non-communicable diseases offered to individuals with low socioeconomic positions. Despite successful recruitment of patients, the intervention had no effect. One reason for the lack of effectiveness could be low rates of referral to behaviour-change programmes in the municipality, resulting in a low dose of the intervention delivered. The aim of this study is to examine the referral pattern of the general practitioners and potential barriers to referring eligible patients to these behaviour-change programmes. METHODS: A mixed-method design was used, including patients' questionnaires, recording sheet from the health checks and semi-structured qualitative interviews with general practitioners. All data used in the study were collected during the time of the intervention. Logistic regressions were used to estimate odds ratios for being eligible and for receiving referrals. The qualitative empirical material was analysed thematically. Emerging themes were grouped, discussed and the material was re-read. The themes were reviewed alongside the analysis of the quantitative material to refine and discuss the themes. RESULTS: Of the 364 patients, who attended the health check, 165 (45%) were marked as eligible for a referral to behaviour-change programme by their general practitioner and of these, 90 (55%) received referrals. Daily smoking (OR = 3.22; 95% CI:2.01-5.17), high-risk alcohol consumption (OR = 2.66; 95% CI:1.38-5.12), obesity (OR = 2.89; 95% CI:1.61-5.16) and poor lung function (OR = 2.05; 95% CI:1.14-3.70) were all significantly associated with being eligible, but not with receiving referral. Four themes emerged as the main barriers to referring patients to behaviour-change programmes: 1) general practitioners' responsibility and ownership for their patients, 2) balancing information and accepting a rejection, 3) assessment of the right time for behavioural change and 4) general practitioners' attitudes towards behaviour-change programmes in the municipality. CONCLUSION: We identified important barriers among the general practitioners which influenced whether the patients received referrals to behaviour-change programmes in the municipality and thereby influenced the dose of intervention delivered in Check-In. The findings suggest that an effort is needed to assist the collaboration between general practices and the municipalities' primary preventive services. TRIAL REGISTRATION: Clinical Trials NCT01979107 ; October 25, 2013.

The effectiveness of general practice-based health checks on health behaviour and incidence on non-communicable diseases in individuals with low socioeconomic position: a randomised controlled trial in Denmark.

BACKGROUND: The effectiveness of health checks aimed at the general population is disputable. However, it is not clear whether health checks aimed at certain groups at high risk may reduce adverse health behaviour and identify persons with metabolic risk factors and non-communicable diseases (NCDs). OBJECTIVES: To assess the effect of general practice-based health checks on health behaviour and incidence on NCDs in individuals with low socioeconomic position. METHODS: Individuals with no formal education beyond lower secondary school and aged 45-64 years were randomly assigned to the intervention group of a preventive health check or to control group of usual care in a 1:1 allocation. Randomisation was stratified by gender and 5-year age group. Due to the real-life setting, blinding of participants was only possible in the control group. Effects were analysed as intention to treat (ITT) and per protocol. The trial was undertaken in 32 general practice units in Copenhagen, Denmark. INTERVENTION: Invitation to a prescheduled preventive health check from the general practitioner (GP) followed by a health consultation and an offer of follow-up with health risk behaviour change or preventive medical treatment, if necessary. PRIMARY OUTCOME MEASURES: Smoking status at 12-month follow-up. Secondary outcomes included status in other health behaviours such as alcohol consumption, physical activity and body mass index (measured by self-administered questionnaire), as well as incidence of metabolic risk factors and NCDs such as hypertension, hypercholesterolaemia, chronic obstructive pulmonary disease, diabetes mellitus, hypothyroidism, hyperthyroidism and depression (drawn from national healthcare registries). RESULTS: 1104 participants were included in the study. For the primary outcome, 710 participants were included in the per protocol analysis, excluding individuals who did not attend the health check, and 1104 participants were included in the ITT analysis. At 12-month follow-up, 37% were daily smokers in the intervention group and 37% in the control group (ORs=0.99, 95% CI: 0.76 to 1.30). No difference in health behaviour nor in the incidence of metabolic risk factors and NCDs between the intervention and control group were found. Side effects were comparable across the two groups. CONCLUSION: The lack of effectiveness may be due to low intensity of intervention, a high prevalence of metabolic risk factors and NCDs among the participants at baseline as well as a high number of contacts with the GPs in general or to the fact that general practices are not an effective setting for prevention. TRIAL REGISTRATION NUMBER: NCT01979107.

Using general practitioners to recruit individuals with low socioeconomic position to preventive health checks is feasible: a cross sectional study.

Objective: To test whether demographic and health-related characteristics are associated with non-attendance of preventive health checks offered to individuals with low levels of education using proactive recruitment by the general practitioners. Design: A cross-sectional study. Setting: 32 general practice clinics in Copenhagen, Denmark. Subjects: A total of 549 individuals aged 45-64, with low levels of education, enrolled in the intervention group of a randomised controlled trial on preventive health checks offered by general practitioner. Main outcome measures: Non-attendance of the preventive health checks. Methods: (i) Descriptive characteristics of attendees and non-attendees and (ii) crude and adjusted multi-level logistic regression to examine associations of individual characteristics with non-attendance of preventive health checks. Results: Overall, 33% did not attend the prescheduled preventive health checks at their general practitioners. Non-attendees were more likely to live without a partner, be of non-Western origin, be daily smokers, have poor self-rated health, have higher pulmonary symptoms score, have increased level of stress, have low levels of self-efficacy, have metabolic risk factors or non-communicable diseases and have had no contact with their general practitioner within the past year. Conclusion: The findings suggest that, it is feasible to use general practitioners for recruiting individuals for preventive health checks. However, even in a trial targeting individuals with low levels of education, there are differences between attendees and non-attendees, with a more adverse health behaviour profile and worse health status observed among the non-attendees. KEY POINTS Current awareness • Non-attendance of preventive health checks offered to the general population is associated with low socioeconomic position and adverse health behaviours. Main statements • It is feasible to use general practitioners proactively in recruitment to preventive health checks offered to individuals with low socioeconomic positions. • In a trial targeting individuals with low levels of education, there were differences between attendees and non-attendees. • Non-attendance was associated with daily smoking, poor self-rated health, high stress and no contact with the general practitioner within the last year.

Motivation and social capital among prospective blood donors in three large blood centers in Brazil.

BACKGROUND: Studies analyzing motivation factors that lead to blood donation have found altruism to be the primary motivation factor; however, social capital has not been analyzed in this context. Our study examines the association between motivation factors (altruism, self-interest, and response to direct appeal) and social capital (cognitive and structural) across three large blood centers in Brazil. STUDY DESIGN AND METHODS: We conducted a cross-sectional survey of 7635 donor candidates from October 15 through November 20, 2009. Participants completed self-administered questionnaires on demographics, previous blood donation, human immunodeficiency virus testing and knowledge, social capital, and donor motivations. Enrollment was determined before the donor screening process. RESULTS: Among participants, 43.5 and 41.7% expressed high levels of altruism and response to direct appeal, respectively, while only 26.9% expressed high levels of self-interest. More high self-interest was observed at Hemope-Recife (41.7%). Of participants, 37.4% expressed high levels of cognitive social capital while 19.2% expressed high levels of structural social capital. More high cognitive and structural social capital was observed at Hemope-Recife (47.3 and 21.3%, respectively). High cognitive social capital was associated with high levels of altruism, self-interest, and response to direct appeal. Philanthropic and high social altruism were associated with high levels of altruism and response to direct appeal. CONCLUSION: Cognitive and structural social capital and social altruism are associated with altruism and response to direct appeal, while only cognitive social capital is associated with self-interest. Designing marketing campaigns with these aspects in mind may help blood banks attract potential blood donors more efficiently.

Vasopressin secretion in response to osmotic stimulation and effects of desmopressin on urinary concentrating capacity in dogs with pyometra.

OBJECTIVE: To determine vasopressin (VP) secretory capacity during osmotic stimulation and the response to desmopressin treatment in dogs with pyometra and control dogs. ANIMALS: 6 dogs with pyometra before and after ovariohysterectomy and 6 control dogs. PROCEDURE: Urine osmolality (Uosm) was measured during 12 hours. Values measured on the first day defined the basal Uosm pattern. On the second day, dogs were given desmopressin to induce a desmopressin-stimulated Uosm pattern. On day 3, the VP response to osmotic stimulation was examined. RESULTS: Median Uosm on day 1 was 340 mOsm/kg (range, 104 to 1,273 mOsm/kg) and 807 mOsm/kg (range, 362 to 1,688 mOsm/kg) in dogs with pyometra before and after surgery, respectively, and 1,511 mOsm/kg (range, 830 to 1,674 mOsm/kg) in control dogs. Median Uosm during desmopressin treatment was 431 mOsm/kg (range, 168 to 1,491 mOsm/kg) and 1,051 mOsm/kg (range, 489 to 1,051 mOsm/kg) in dogs with pyometra before and after surgery, respectively, and 1,563 mOsm/kg (range, 1,390 to 2,351) in control dogs. In dogs with pyometra, threshold for VP secretion was lower before surgery (median, 340 mOsm/kg; range, 331 to 366 mOsm/kg) than after surgery (median, 358 mOsm/kg; range, 343 to 439 mOsm/kg) or in control dogs (median, 347 mOsm/kg; range, 334 to 360 mOsm/kg). Highest maximum plasma VP values were found in dogs with pyometra. CONCLUSIONS AND CLINICAL RELEVANCE: Dogs with pyometra had increased urine concentration in response to desmopressin but not to the degree of control dogs, whereas VP secretory ability was not reduced.

Risk of tuberculin skin test conversion among health care workers: occupational versus community exposure and infection.

A prospective observational cohort study to assess rates of and risk factors for tuberculin skin test (TST) conversion among health care workers (HCWs) was conducted at an urban hospital located in a high tuberculosis-incidence area in 1994-1998. All hospital employees undergoing required testing every 6 months were included. A total of 69 (1.2%) of 5773 susceptible employees had a documented TST conversion (overall rate, 0.38 per 100 person-years worked). No significant difference existed in conversion rates among employees with frequent, limited, or no patient contact. HCWs with a TST conversion lived in zip codes with higher tuberculosis case rates (P< or =.05). In multivariate analysis, TST conversion was associated with history of bacille Calmette-Guérin vaccination (relative risk [RR], 11.63), annual salary <$20,000 (RR, 3.67), and increasing age. In the setting of an effective tuberculosis infection-control program, TST conversion rates were low, and risk of conversion among HCWs was associated most strongly with nonoccupational factors.

Increased survival of persons with tuberculosis and human immunodeficiency virus infection, 1991--2000.

To determine factors associated with the occurrence of human immunodeficiency virus (HIV) infection and tuberculosis (TB) disease (HIV-TB) and the associated survival rate, we analyzed patients with HIV-TB at Grady Memorial Hospital, Atlanta, Georgia, from 1991 through 2000. Overall, 644 patients with HIV-TB were seen. The number of HIV-TB cases per year was highest in 1992 (102 cases) and declined to 39 cases in 2000. Over time, patients were more likely to be enrolled in the HIV outpatient clinic (P<.01), but, in 1997, only 21 (51%) of 41 patients were enrolled in HIV-infection care programs and only 9 (22%) of 41 received HAART. The 1-year survival rate for patients with HIV-TB was 58% in 1991, 81% in 1994, and 83% in 1997 (P<.001). The increase in survival for patients with HIV-TB between 1991 and 1994 was likely due to improved TB and HIV therapy. More effective strategies for enrolling and maintaining HIV-TB patients in HIV-infection care programs could further increase survival.

Risk factors for methicillin-resistance among patients with Staphylococcus aureus bacteremia at the time of hospital admission.

BACKGROUND: Community-acquired infections caused by methicillin-resistant Staphylococcus aureus (MRSA) seem to be increasing. Characteristics permitting recognition of patients with such strains would aid infection control efforts and choice of empiric therapy pending culture and susceptibility results. METHODS: Retrospective review of medical records for all adults seen in the Emergency Care Center at Grady Memorial Hospital, Atlanta, Georgia, whose blood cultures taken within 24 hours of entry yielded S. aureus. Risk factors for the presence of methicillin resistance in S. aureus isolates recovered from patients with staphylococcal bacteremia were assessed. RESULTS: S. aureus isolates from 118 (40%) of 297 study patients with bacteremia at the time of admission were methicillin-resistant. Multivariate analysis identified hospitalization in the 6 months preceding admission [odds ratio (OR) = 4.4; 95% CI, 2.0-9.8], receipt of antimicrobial agents in the past 3 months (OR = 5.6; 95% CI, 2.6-11.9], presence of indwelling urinary catheter (OR = 7.3; CI, 2.5-20.9), and nursing home residence (OR = 9.9; 95% CI, 3.9-25.6) to be independently associated with the presence of methicillin resistance. All but 4 of the 118 patients with methicillin-resistant strains had at least 1 of these factors and the proportion of resistant isolates progressively increased as more of these features were present. CONCLUSIONS: The presence of these risk factors should be considered when making decisions about isolation and other infection control procedures as well as empiric antimicrobial therapy with vancomycin for patients with suspected staphylococcal infection at the time of hospital admission. Similar studies could guide practices for dealing with such patients in other centers, because the occurrence of MRSA infections at the time of admission may vary widely by geographic area.

Human papillomavirus-associated oral warts among human immunodeficiency virus-seropositive patients in the era of highly active antiretroviral therapy: an emerging infection.

Oral warts are a manifestation of human papillomavirus infection that have been noted infrequently in persons with human immunodeficiency virus (HIV). A nested case-control study was conducted to assess rates of and risk factors for oral warts among a cohort of HIV-seropositive patients. From 1997 through 1999, 56 patients with oral warts were identified among 2194 HIV-positive patients attending an urban oral health center (prevalence, 2.6%). Incident cases of oral warts were significantly more likely to have been diagnosed in 1999 than they were in 1997-1998 (P=.001). Multivariate analysis indicated that the risk of oral warts was associated with a >/=1-log(10) decrease in HIV RNA level in the 6 months before diagnosis of oral warts (odds ratio [OR], 2.35; 95% confidence interval [CI], 1.08-5.11) and with serologic evidence of chronic or previous infection with hepatitis B virus (OR, 2.66; 95% CI, 1.31-5.41). The incidence of oral warts in HIV-seropositive patients appears to be increasing in the era of highly active antiretroviral therapy. Oral warts were associated with reductions in virus load, which suggests that this may in part be related to immune reconstitution.