Chronic comorbid conditions and asthma exacerbation occurrence in a general population sample.

Chronic comorbid conditions are common in adults with asthma, and some may influence a patient's asthma exacerbation risk. We explored associations between eighteen chronic comorbid conditions and asthma exacerbation occurrence in adults with asthma in a cross-sectional study nested within a cohort study using data from the two-yearly US National Health and Nutrition Examination Survey (NHANES) program. Data of 2387 adults with self-reported doctor-diagnosed current asthma from the 2007 to 2018 NHANES surveys were selected. Investigated chronic comorbidities were: angina pectoris; congestive heart failure; coronary heart disease; depression; diabetes mellitus; soft and hard drug use; gastroesophageal reflux; gout; history of heart attack; history of stroke; hypercholesterolemia; hypertension; kidney failure; liver conditions; obesity; rheumatoid arthritis; and thyroid problems. Outcome was defined as asthma exacerbation category: no, moderate, or severe exacerbation(s) in the past year. Ordinal logistic regression analysis with correction for potential confounders was used to estimate odds ratios (OR) for moderate or severe exacerbations. Observed associations with increased severe asthma exacerbation occurrence were: obesity (OR = 1.67; 95% confidence interval 1.24, 2.26), and rheumatoid arthritis (OR = 1.55; 1.04, 2.30). History of stroke (OR = 1.95; 1.22, 3.11) and rheumatoid arthritis (OR = 1.33; 1.00, 1.75) showed associations with increased moderate exacerbation occurrence. Age-stratified analysis showed soft drug use, obesity, depression, thyroid problems, and rheumatoid arthritis to be associated with moderate and/or severe exacerbation occurrence in one or more 10-year age strata. In conclusion, several chronic comorbid conditions were associated with asthma exacerbation occurrence, which confirms but also complements previous studies. Our observations contribute to understanding exacerbation risk estimation and, ultimately, personalized asthma management.

25-year retrospective longitudinal study on seasonal allergic rhinitis associations with air temperature in general practice.

Due to climate change, air temperature in the Netherlands has gradually increased. Higher temperatures lead to longer pollen seasons. Possible relations between air temperature and increased impact of seasonal allergic rhinitis (SAR) in general practice have not been investigated yet. We explored trends in timing of frequent seasonal allergic rhinitis presentation to general practitioners (GPs) over 25 years and explored associations with air temperature. We performed a retrospective exploratory longitudinal study with data from our Family Medicine Network (1995-2019), including all SAR patients and their GP-encounters per week. We determined patients' GP-consultation frequency. Every year we identified seasonal periods with substantial increase in SAR related encounters: peak-periods. We determined start date and duration of the peak-period and assessed associations with air temperature in the beginning and throughout the year, respectively. The peak-period duration increased by a mean of 1.3 days (95% CI 0.23-2.45, P = 0.02) per year throughout the study period. Air temperature between February and July showed a statistically significant association with peak-period duration. We could not observe direct effects of warmer years on the start of peak-periods within distinct years (P = 0.06). SAR patients' contact frequency slightly increased by 0.01 contacts per year (95% CI 0.002-0.017, P = 0.015). These longitudinal findings may help to facilitate further research on the impact of climate change, and raise awareness of the tangible impact of climate change in general practice.

Purposeful Incorporation of Patient Narratives in the Medical Record in the Netherlands.

INTRODUCTION: Structuring patient and practice data into episodes formed the foundation of the earliest evidence base of family medicine. We aim to make patients' narratives part of the evidence base for family medicine by incorporating coded and structured information on the patient's reason to visit the family physician (FP) and adding the patient's personal and contextual characteristics to routine registration data. This documentation allows studies of relations between morbidity and elements of the patient story, providing more insight into the range of problems presented to primary care and in the patient-centeredness applied by FPs. METHODS: The Dutch Practice-Based Research Network (PBRN), named FaMe-Net, is the world's oldest PBRN. Seven Dutch family practices provide regular primary care and participate in the PBRN. It contains all morbidity data of the approximately 40,000 listed patients (308,000 patient-years and 2.2 million encounters from 2005 until 2019). All information belonging to 1 health problem is ordered in 1 episode. Morbidity (diagnoses), reasons for encounter (RFE), and interventions are coded according to the International Classification of Primary Care (ICPC-2). Registration occurs within the electronic health record (EHR), specially designed to facilitate the extensive registration for the PBRN. Since 2016, the network expanded routine registration with the duration of symptoms and coded personal and contextual characteristics (eg, country of birth, level of education, family history, traumatic events) obtained through the self-reported 'context survey' of listed patients. These data are added to the EHR. Registered data are extracted from the EHR and processed for scientific research.We present data on the differences in RFEs of the most prominent symptoms of COVID-19 between 2019 and 2020; the relation between the diagnosis of pneumonia and presentation of the symptom 'cough,' and how personal determinants influence the chances of final diagnoses. Lastly, we show the relation of self-reported abuse with patient's contact frequency and psychosocial problems. RESULTS: Prompt introduction of registration rules brought insight into COVID-19-related symptoms early in the pandemic. In March 2020, symptoms related to COVID-19 were presented more often than in March 2019. Chronic conditions and prevention showed a collapsing contact frequency. Telephone, email, and video consultations increased from 31% to 53%.Episodes of pneumonia most frequently started with the RFE 'cough.' A combination of 'cough' and 'fever' as RFE increases the likelihood of pneumonia, as does cough in the presence of comorbid COPD among older men. The prevalence of pneumonia is higher among patients with low socioeconomic status. DISCUSSION: The Dutch PBRN FaMe-Net has started to add elements of patients' narratives and context to decades of morbidity registration, creating options for a scientific approach to primary care's core values. Assumptions of 'pre/post chances' of the final diagnosis, already existing implicitly in FPs minds, can be elaborated and quantified by investigating the associations between multiple registered variables, including parts of patients' 'stories.' This way, we aim to make visible what is intuitively already known by FPs.

Are asthma patients at increased risk of clinical depression? A longitudinal cohort study.

OBJECTIVE: In this study, we assessed whether adult patients with asthma are more likely to be diagnosed with depression than diabetes patients or "healthy" controls during follow-up in primary care. METHODS: Data from the Nijmegen Continuous Morbidity Registration were used to assess the risk for a first depression. Patients with asthma were compared with patients with diabetes and with two healthy controls matched on age, gender, socioeconomic status and attending general practice. With Cox proportional hazard analysis, we compared the risk of depression between these groups. These analyses were corrected for relevant covariates including a time-depending variable for multimorbidity. Explorative subgroup analyses were done for age, gender, socioeconomic status and multimorbidity. RESULTS: Cumulative incidence of depression in asthma patients was 5.2%, in DM patients 4.1% and in control subjects 3.3%. The hazard ratios for a first episode of depression in the asthma patients (n = 795) compared to DM patients (n = 1033) and control subjects after correction for covariates were 1.11 (95% CI 0.60-2.04) and 1.18 (95% CI 0.78-1.79), respectively. Exploratory analyses showed that asthma patients without multimorbidity were at higher risk for a depression compared to reference groups, while asthma patients with multimorbidity were at lower risk for depression. CONCLUSION: Asthma patients were not more likely to be diagnosed with a first depression compared to "healthy" control subjects or diabetes patients. The influence of multimorbidity on depression risk in asthma patients warrants further study.

How GPs value guidelines applied to patients with multimorbidity: a qualitative study.

OBJECTIVES: To explore and describe the value general practitioner (GPs) attribute to medical guidelines when they are applied to patients with multimorbidity, and to describe which benefits GPs experience from guideline adherence in these patients. Also, we aimed to identify limitations from guideline adherence in patients with multimorbidity, as perceived by GPs, and to describe their empirical solutions to manage these obstacles. DESIGN: Focus group study with purposive sampling of participants. Focus groups were guided by an experienced moderator who used an interview guide. Interviews were transcribed verbatim. Data analysis was performed by two researchers using the constant comparison analysis technique and field notes were used in the analysis. Data collection proceeded until saturation was reached. SETTING: Primary care, eastern part of The Netherlands. PARTICIPANTS: Dutch GPs, heterogeneous in age, sex and academic involvement. RESULTS: 25 GPs participated in five focus groups. GPs valued the guidance that guidelines provide, but experienced shortcomings when they were applied to patients with multimorbidity. Taking these patients' personal circumstances into account was regarded as important, but it was impeded by a consistent focus on guideline adherence. Preventative measures were considered less appropriate in (elderly) patients with multimorbidity. Moreover, the applicability of guidelines in patients with multimorbidity was questioned. GPs' extensive practical experience with managing multimorbidity resulted in several empirical solutions, for example, using their 'common sense' to respond to the perceived shortcomings. CONCLUSIONS: GPs applying guidelines for patients with multimorbidity integrate patient-specific factors in their medical decisions, aiming for patient-centred solutions. Such integration of clinical experience and best evidence is required to practise evidence-based medicine. More flexibility in pay-for-performance systems is needed to facilitate this integration. Several improvements in guideline reporting are necessary to enhance the applicability of guidelines in patients with multimorbidity.

The Effect of Comorbidity on Glycemic Control and Systolic Blood Pressure in Type 2 Diabetes: A Cohort Study with 5 Year Follow-Up in Primary Care.

AIMS: To explore the longitudinal effect of chronic comorbid diseases on glycemic control (HbA1C) and systolic blood pressure (SBP) in type 2 diabetes patients. METHODS: In a representative primary care cohort of patients with newly diagnosed type 2 diabetes in The Netherlands (n = 610), we tested differences in the five year trend of HbA1C and SBP according to comorbidity profiles. In a mixed model analysis technique we corrected for relevant covariates. Influence of comorbidity (a chronic disease already present when diabetes was diagnosed) was tested as total number of comorbid diseases, and as presence of specific disease groups, i.e. cardiovascular, mental, and musculoskeletal disease, malignancies, and COPD. In subgroup effect analyses we tested if potential differences were modified by age, sex, socioeconomic status, and BMI. RESULTS: The number of comorbid diseases significantly influenced the SBP trend, with highest values after five years for diabetes patients without comorbidity (p = 0.005). The number of diseases did not influence the HbA1C trend (p = 0.075). Comorbid musculoskeletal disease resulted in lower HbA1C at the time of diabetes diagnosis, but in higher values after five years (p = 0.044). Patients with cardiovascular diseases had sustained elevated levels of SBP (p = 0.014). Effect modification by socioeconomic status was observed in some comorbidity subgroups. CONCLUSIONS: Presence of comorbidity in type 2 diabetes patients affected the long-term course of HbA1C and SBP in this primary care cohort. Numbers and types of comorbidity showed differential effects: not the simple sum of diseases, but specific types of comorbid disease had a negative influence on long-term diabetes control parameters. The complex interactions between comorbidity, diabetes control and effect modifiers require further investigation and may help to personalize treatment goals.

Exploring the impact of chronic obstructive pulmonary disease (COPD) on diabetes control in diabetes patients: a prospective observational study in general practice.

BACKGROUND: Little is known about the association between COPD and diabetes control parameters. AIMS: To explore the association between comorbid COPD and longitudinal glycaemic control (HbA1C) and systolic blood pressure (SBP) in a primary care cohort of diabetes patients. METHODS: This is a prospective cohort study of type 2 diabetes patients in the Netherlands. In a mixed model analysis, we tested differences in the 5-year longitudinal development of HbA1C and SBP according to COPD comorbidity (present/absent). We corrected for relevant covariates. In subgroup effect analyses, we tested whether potential differences between diabetes patients with/without COPD were modified by age, sex, socio-economic status (SES) and body mass index (BMI). RESULTS: We analysed 610 diabetes patients. A total of 63 patients (10.3%) had comorbid COPD. The presence of COPD was not significantly associated with the longitudinal development of HbA1C (P=0.54) or SBP (P=0.33), but subgroup effect analyses showed significant effect modification by SES (P<0.01) and BMI (P=0.03) on SBP. Diabetes patients without COPD had a flat SBP trend over time, with higher values in patients with a high BMI. For diabetes patients with COPD, SBP gradually increased over time in the middle- and high-SES groups, and it decreased over time in those in the low-SES group. CONCLUSIONS: The longitudinal development of HbA1C was not significantly associated with comorbid COPD in diabetes patients. The course of SBP in diabetes patients with COPD is significantly associated with SES (not BMI) in contrast to those without COPD. Comorbid COPD was associated with longitudinal diabetes control parameters, but it has complex interactions with other patient characteristics. Further research is needed.

Prevalence and incidence density rates of chronic comorbidity in type 2 diabetes patients: an exploratory cohort study.

BACKGROUND: Evidence-based diabetes guidelines generally neglect comorbidity, which may interfere with diabetes management. The prevalence of comorbidity described in patients with type 2 diabetes (T2D) shows a wide range depending on the population selected and the comorbid diseases studied. This exploratory study aimed to establish comorbidity rates in an unselected primary-care population of patients with T2D. METHODS: This was a cohort study of 714 adult patients with newly diagnosed T2D within the study period (1985-2007) in a practice-based research network in the Netherlands. The main outcome measures were prevalence and incidence density rates of chronic comorbid diseases and disease clusters. All chronic disease episodes registered in the practice-based research network were considered as comorbidities. We categorised comorbidity into 'concordant' (that is, shared aetiology, risk factors, and management plans with diabetes) and 'discordant' comorbidity. Prevalence and incidence density were assessed for both categories of comorbidity. RESULTS: The mean observation period was 17.3 years. At the time of diabetes diagnosis, 84.6% of the patients had one or more chronic comorbid disease of 'any type', 70.6% had one or more discordant comorbid disease, and 48.6% and 27.2% had three or more chronic comorbid diseases of 'any type' or of 'discordant only', respectively. A quarter of those without any comorbid disease at the time of their diabetes diagnosis developed at least one comorbid disease in the first year afterwards. Cardiovascular diseases (considered concordant comorbidity) were the most common, but there were also high rates of musculoskeletal and mental disease. Discordant comorbid diseases outnumbered concordant diseases. CONCLUSIONS: We found high prevalence and incidence density rates for both concordant and discordant comorbidity. The latter may interfere with diabetes management, thus future research and clinical practice should take discordant comorbidity in patients with T2D into account.

GPs' considerations in multimorbidity management: a qualitative study.

BACKGROUND: Scientific evidence on how to manage multimorbidity is limited, but GPs have extensive practical experience with multimorbidity management. AIM: To explore GPs' considerations and main objectives in the management of multimorbidity and to explore factors influencing their management of multimorbidity. DESIGN AND SETTING: Focus group study of Dutch GPs; with heterogeneity in characteristics such as sex, age and urbanisation. METHOD: The moderator used an interview guide in conducting the interviews. Two researchers performed the analysis as an iterative process, based on verbatim transcripts and by applying the technique of constant comparative analysis. Data collection proceeded until saturation was reached. RESULTS: Five focus groups were conducted with 25 participating GPs. The main themes concerning multimorbidity management were individualisation, applying an integrated approach, medical considerations placed in perspective, and sharing decision making and responsibility. A personal patient-doctor relationship was considered a major factor positively influencing the management of multimorbidity. Mental-health problems and interacting conditions were regarded as major barriers in this respect and participants experienced several practical problems. The concept of patient-centredness overarches the participants' main objectives. CONCLUSION: GPs' main objective in multimorbidity management is applying a patient-centred approach. This approach is welcomed since it counteracts some potential pitfalls of multimorbidity. Further research should include a similar design in a different setting and should aim at developing best practice in multimorbidity management.