Long-term trajectories of employment status, workhours and disability support pension status, after a first episode of CNS demyelination.

BACKGROUND: People with multiple sclerosis face significant employment-related challenges, with little known of the drivers of these outcomes. OBJECTIVE: We examined prospective trajectories of employment-related outcomes up to 11 years following a first episode of central nervous system (CNS) demyelination (FCD). METHODS: Participants were aged 18-59 years, at FCD, with at least two observations and were employed at study entry or anytime during follow-up (n = 207). Outcomes were employment status (full-time, part-time and unemployed), average workhours per week and disability support pension (DSP; receiving/not receiving). We used group-based trajectory modelling to identify groups with common trajectories. Factors associated with trajectory membership were explored using log-multinomial regression. RESULTS: Distinct trajectories were identified for employment (4), workhours (4) and DSP (2). Compared with stable full-time, female sex was strongly associated with being in the stable part-time trajectory (risk ratio (RR): 5.35; 95% confidence interval (CI) = 2.56-11.20; p < 0.001). A greater level of disability at 5-year review (RR: 1.35; 95% CI = 1.19-1.53) and having more than two comorbidities at baseline (RR: 2.77; 95% CI = 1.37-5.64) were associated with being in early and late deteriorated employment trajectories, respectively. Compared with the increased part-time trajectory, every additional relapse during the 5 years post-FCD was associated with a 10% increased risk of being in the reduced part-time trajectory (RR = 1.10; 95%CI = 1.00-1.22). For every additional EDSS point at 5-year review, the risk of being in the DSP trajectory increased (RR = 1.21; 95% CI = 1.05-1.41). CONCLUSION: These trajectories indicate substantial heterogeneity and the complex impact of MS on employment from its earliest timepoints. Understanding these trends could enable better targeting of interventions to facilitate workforce retention, particularly for females, those with a higher number of comorbidities, more frequent relapses and greater rate of disability accrual.

Multimorbidity, healthcare use and catastrophic health expenditure by households in India: a cross-section analysis of self-reported morbidity from national sample survey data 2017-18.

BACKGROUND: The purpose of this research is to generate new evidence on the economic consequences of multimorbidity on households in terms of out-of-pocket (OOP) expenditures and their implications for catastrophic OOP expenditure. METHODS: We analyzed Social Consumption Health data from National Sample Survey Organization (NSSO) 75th round conducted in the year 2017-2018 in India. The sample included 1,13,823 households (64,552 rural and 49,271 urban) through a multistage stratified random sampling process. Prevalence of multimorbidity and related OOP expenditure were estimated. Using Coarsened Exact Matching (CEM) we estimated the mean OOP expenditure for individuals reporting multimorbidity and single morbidity for each episode of outpatient visits and hospital admission. We also estimated implications in terms of catastrophic OOP expenditure for households. RESULTS: Results suggest that outpatient OOP expenditure is invariably lower in the presence of multimorbidity as compared with single conditions of the selected Non-Communicable Diseases(NCDs) (overall, INR 720 [USD 11.3] for multimorbidity vs. INR 880 [USD 14.8] for single). In the case of hospitalization, the OOP expenditures were mostly higher for the same NCD conditions in the presence of multimorbidity as compared with single conditions, except for cancers and cardiovascular diseases. For cancers and cardiovascular, OOP expenditures in the presence of multimorbidity were lower by 39% and 14% respectively). Furthermore, around 46.7% (46.674-46.676) households reported incurring catastrophic spending (10% threshold) because of any NCD in the standalone disease scenario which rose to 63.3% (63.359-63.361) under the multimorbidity scenario. The catastrophic implications of cancer among individual diseases was the highest. CONCLUSIONS: Multimorbidity leads to high and catastrophic OOP payments by households and treatment of high expenditure diseases like cancers and cardiovascular are under-financed by households in the presence of competing multimorbidity conditions. Multimorbidity should be considered as an integrated treatment strategy under the existing financial risk protection measures (Ayushman Bharat) to reduce the burden of household OOP expenditure at the country level.

Comorbidity patterns in people with multiple sclerosis: A latent class analysis of the Australian Multiple Sclerosis Longitudinal Study.

BACKGROUND AND PURPOSE: This study was undertaken to identify clinically meaningful comorbidity patterns and their associations with the demographic/clinical characteristics of people with multiple sclerosis (MS). METHODS: We conducted latent class analysis to identify clinically distinct comorbidity patterns in MS using the 15 most common comorbidities among 1518 Australian Multiple Sclerosis Longitudinal Study participants. The associations between demographic/clinical characteristics and comorbidity patterns were examined using log-binomial and multinomial logistic regression. RESULTS: Five distinct comorbidity patterns were identified: "minimally diseased class" (30.8%), consisting of participants with no or one comorbidity; "metabolic class" (22.7%); "mental health-allergy class" (21.7%); "nonmetabolic class" (7.6%); and "severely diseased class" (7.0%), consisting of participants with higher prevalence of these comorbidities. The relative probabilities of being assigned to comorbidity classes compared to the minimally diseased class were significantly increased for participants who were older (metabolic: relative risk ratio [RRR] = 1.09, 95% confidence interval [CI] = 1.06-1.11; nonmetabolic: RRR = 1.07, 95% CI = 1.04-1.11; severely diseased: RRR = 1.04, 95% CI = 1.01-1.08), female (nonmetabolic: RRR = 5.35, 95% CI = 1.98-14.42; severely diseased: RRR = 2.21, 95% CI = 1.02-4.77), and obese (metabolic: RRR = 4.06, 95% CI = 2.45-6.72; mental health-allergy: RRR = 1.57, 95% CI = 1.00-2.46; severely diseased: RRR = 4.53, 95% CI = 2.21-9.29) and who had moderate disability (mental health-allergy: RRR = 2.32, 95% CI = 1.47-3.64; severely diseased: RRR = 2.65, 95% CI = 1.16-6.04). CONCLUSIONS: Comorbidity patterns exist in MS. Women, people who were older, people who were obese, and people who had higher disability levels were more likely to be in classes with higher levels of comorbidity. These findings may offer opportunities for designing more personalised approaches to comorbidity prevention and treatment.

The Burden of Cardiovascular Disease Attributable to Major Modifiable Risk Factors in Indonesia.

BACKGROUND: In Indonesia, coronary heart disease (CHD) and stroke are estimated to cause more than 470 000 deaths annually. In order to inform primary prevention policies, we estimated the sex- and age-specific burden of CHD and stroke attributable to five major and modifiable vascular risk factors: cigarette smoking, hypertension, diabetes, elevated total cholesterol, and excess body weight. METHODS: Population attributable risks for CHD and stroke attributable to these risk factors individually were calculated using summary statistics obtained for prevalence of each risk factor specific to sex and to two age categories (<55 and ≥55 years) from a national survey in Indonesia. Age- and sex-specific relative risks for CHD and stroke associated with each of the five risk factors were derived from prospective data from the Asia-Pacific region. RESULTS: Hypertension was the leading vascular risk factor, explaining 20%-25% of all CHD and 36%-42% of all strokes in both sexes and approximately one-third of all CHD and half of all strokes across younger and older age groups alike. Smoking in men explained a substantial proportion of vascular events (25% of CHD and 17% of strokes). However, given that these risk factors are likely to be strongly correlated, these population attributable risk proportions are likely to be overestimates and require verification from future studies that are able to take into account correlation between risk factors. CONCLUSIONS: Implementation of effective population-based prevention strategies aimed at reducing levels of major cardiovascular risk factors, especially blood pressure, total cholesterol, and smoking prevalence among men, could reduce the growing burden of CVD in the Indonesian population.

A study of organizational versus individual needs related to recruitment, deployment and promotion of doctors working in the government health system in Odisha state, India.

BACKGROUND: An effective health workforce is essential for achieving health-related new Sustainable Development Goals. Odisha, one of the states in India with low health indicators, faces challenges in recruiting and retaining health staff in the public sector, especially doctors. Recruitment, deployment and career progression play an important role in attracting and retaining doctors. We examined the policies on recruitment, deployment and promotion for doctors in the state and how these policies were perceived to be implemented. METHODS: We undertook document review and four key informant interviews with senior state-level officials to delineate the policies for recruitment, deployment and promotion. We conducted 90 in-depth interviews, 86 with doctors from six districts and four at the state level to explore the perceptions of doctors about these policies. RESULTS: Despite the efforts by the Government of Odisha through regular recruitments, a quarter of the posts of doctors was vacant across all institutional levels in the state. The majority of doctors interviewed were unaware of existing government rules for placement, transfer and promotion. In addition, there were no explicit rules followed in placement and transfer. More than half (57%) of the doctors interviewed from well-accessible areas had never worked in the identified hard-to-reach areas in spite of having regulatory and incentive mechanisms. The average length of service before the first promotion was 26 (±3.5) years. The doctors expressed satisfaction with the recruitment process. They stated concerns over delayed first promotion, non-transparent deployment policies and ineffective incentive system. Almost all doctors suggested having time-bound and transparent policies. CONCLUSIONS: Adequate and appropriate deployment of doctors is a challenge for the government as it has to align the individual aspirations of employees with organizational needs. Explicit rules for human resource management coupled with transparency in implementation can improve governance and build trust among doctors which would encourage them to work in the public sector.

Prevalence, correlates, and outcomes of multimorbidity among patients attending primary care in Odisha, India.

PURPOSE: Little information is available on multimorbidity in primary care in India. Because primary care is the first contact of health care for most of the population and important for coordinating chronic care, we wanted to examine the prevalence and correlates of multimorbidity in India and its association with health care utilization. METHODS: Using a structured multimorbidity assessment protocol, we conducted a cross-sectional study, collecting information on 22 self-reported chronic conditions in a representative sample of 1,649 adult primary care patients in Odisha, India. RESULTS: The overall age- and sex-adjusted prevalence of multimorbidity was 28.3% (95% CI, 24.3-28.6) ranging from 5.8% in patients aged 18 to 29 years to 45% in those aged older than 70 years. Older age, female sex, higher education, and high income were associated with significantly higher odds of multimorbidity. After adjusting for age, sex, socioeconomic status (SES), education, and ethnicity, the addition of each chronic condition, as well as consultation at private hospitals, was associated with significant increase in the number of medicines intake per person per day. Increasing age and higher education status significantly raised the number of hospital visits per person per year for patients with multiple chronic conditions. CONCLUSION: Our findings of higher prevalence of multimorbidity and hospitalizations in higher SES individuals contrast with findings in Western countries, where lower SES is associated with a greater morbidity burden.

Age- and Sex-Specific Burden of Cardiovascular Disease Attributable to 5 Major and Modifiable Risk Factors in 10 Asian Countries of the Western Pacific Region.

Cardiovascular disease (CVD) is the leading cause of mortality worldwide, causing an estimated 18 million deaths annually. Much of the burden of CVD resides in lower- and middle-income countries, particularly those Asian countries comprising the Western Pacific Region. Epidemiological studies have convincingly shown that up to 90% of all CVD can be explained by a small number of modifiable risk factors, including blood pressure, smoking, diabetes, total cholesterol and excess body weight. However, the relationship between these risk factors and coronary artery disease and stroke often differ by age and sex, and yet these differences are often overlooked in burden of disease estimations. As such, that can result in either an over- or under-estimation of the disease burden in specific population subgroups, which may affect resource allocation of healthcare. In this review, we derive the most reliable and previously unpublished estimates of the age- and sex-specific burden of vascular disease attributable to the aforementioned risk factors for 10 of the most populous Asian countries in the Western Pacific Region. Understanding how the burden of vascular disease is distributed within and between populations is crucial for developing appropriate health policies and effective treatment strategies, particularly in resource-poor settings.

The Effect of Right Ventricular Apical and Nonapical Pacing on the Short- and Long-Term Changes in Left Ventricular Ejection Fraction: A Systematic Review and Meta-Analysis of Randomized-Controlled Trials.

BACKGROUND: The right ventricular apex (RVA) is the traditional lead site for chronic pacing but in some patients may cause impaired left ventricular (LV) systolic function over time. Comparisons with right ventricular nonapical (RVNA) pacing sites have generated inconsistent results and recent meta-analyses have demonstrated unclear benefit due to heterogeneity across studies. METHODS AND RESULTS: A systematic search for randomized controlled trials that compared LV ejection fraction (LVEF) outcomes between RVNA and RVA pacing was performed up to October 2014. Twenty-four studies (n = 1,628 patients) met the inclusion criteria. To avoid between study heterogeneity two homogenous groups were created; group 1 where studies reported a difference (in favor of RVNA pacing) and group 2 where studies reported no difference between pacing sites. For group 1, weighted mean difference between RVNA and RVA pacing in terms of LVEF at follow-up was 5.40% (95% confidence interval [CI]: 3.94-6.87), related in part to group one's RVA arm demonstrating a significant reduction (mean loss -3.31%; 95% CI: -6.19 to -0.43) in LVEF between study baseline and end of follow-up. Neither of these finding were seen in group 2. Weighted regression modeling demonstrated that inclusion of poor baseline LVEF (<40%) in combination with greater than 12 months follow-up was three times more common in group 1 compared to group 2 (weighted relative risk 2.82; 95% CI: 1.03-7.72; P = 0.043). CONCLUSIONS: In patients requiring chronic right ventricular pacing where there is inclusion of impaired baseline LVEF (<40%), RVA pacing is associated with deterioration in LV function relative to RVNA pacing.

Non communicable disease multimorbidity and associated health care utilization and expenditures in India: cross-sectional study.

BACKGROUND: Non communicable disease (NCD) multimorbidity is increasingly becoming common in high income settings but little is known about its epidemiology and associated impacts on citizens and health systems in low and middle-income countries (LMICs). We aim to examine the socio-demographic distribution of NCD multimorbidity (≥2 diseases) and its implications for health care utilization and out-of-pocket expenditure (OOPE) in India. METHODS: We analyzed cross-sectional nationally representative data from the World Health Organisaion Study on Global Ageing and Adult Health (WHO-SAGE), conducted in India during 2007. Multiple logistic regression was used to determine socio-demographic predictors of self-reported multimorbidity. A two part model was used to assess the relationship between number of NCDs and health care utilization including OOPE. RESULTS: 28.5% of the sample population had at least one NCD and 8.9% had NCD multimorbidity. The prevalence of multimorbidity increased from 1.3% in 18-29 year olds to 30.6% in those aged 70 years and above. Mean outpatient visits in the preceding 12 months increased from 2.2 to 6.2 and the percentage reporting an overnight hospital stay in the past 3 years increased from 9% to 29% in those with no NCD and ≥2 NCDs respectively (p <0.001).OOPE incurred during the last outpatient visit increased from INR 272.1 (95% CI = 249.0-295.2) in respondents with no NCDs to INR 454.1 (95% CI = 407.8-500.4) in respondents with ≥2 NCDs. However, we did not find an increase in OOPE during the last inpatient visit with number of NCDs (7865.9 INR for those with zero NCDs compared with 7301.3 for those with ≥2 NCDs). For both outpatient and inpatient OOPE, medicine constitutes the largest proportion of spending (70.7% for outpatient, 53.6% for inpatient visit), followed by spending for health care provider (14.0% for outpatient, 12.2% for inpatient visit). CONCLUSION: NCD multimorbidity is common in the Indian adult population and is associated with substantially higher healthcare utilization and OOPE. Strategies to address the growing burden of NCDs in LMICs should include efforts to improve the management of patients with multimorbidity and reduce associated financial burden to individuals and households.

Motivation and job satisfaction among multipurpose health workers in hilly and non-hilly areas of Jashpur District, Chhattisgarh: an exploratory study.

It is essential to have a capable and motivated health workforce for building an effective, responsive health system and in turn achieve national health goals. The present cross sectional study was conducted in Chhattisgarh, India to assess the level of motivation and job satisfaction among multipurpose health workers (MPWs) and to study factors influencing them. A pre-tested semistructured questionnaire was used to obtain information about the respondents' perceived importance of various job characteristics and perceived job satisfaction. The majority of MPWs were not satisfied with their existing job conditions. Motivators or satisfiers like career advancement and achievement had low scores for all the participants. Working conditions and salary were found to be the dissatisfiers with low scores. The present study suggests that, although financial incentives are important, they are not sufficient to motivate personnel to perform better.

Children and adolescents are not small adults: toward a better understanding of multimorbidity in younger populations.

Multimorbidity is of an increasing importance for the health of both children and adults but research has hitherto focused on adult multimorbidity. Hence, public awareness, practice, and policy lack vital information about multimorbidity in childhood and adolescence. We convened an international and interdisciplinary group of experts from six nations to identify key priorities supported by published evidence to strengthen research for children and adolescent with multimorbidity. Future research is encouraged (1) to develop a conceptual framework to capture unique aspects of child and adolescent multimorbidity-including definitions, characteristic patterns of conditions for different age groups, its dynamic nature through childhood and adolescence, and understanding of severity and trajectories for different clusters of multiple chronic conditions, (2) to define new indices to classify the presence of multimorbidity in children and adolescents, (3) to improve the availability and linkage of data across countries, (4) to synthesize evidence on the global phenomenon of multimorbidity in childhood and adolescence and health inequalities, and (5) to involve children and adolescents in research relevant to their health.

Public health engineering education in India: current scenario, opportunities and challenges.

Public health engineering can play an important and significant role in solving environmental health issues. In order to confront public health challenges emerging out of environmental problems we need adequately trained public health engineers / environmental engineers. Considering the current burden of disease attributable to environmental factors and expansion in scope of applications of public health / environmental engineering science, it is essential to understand the present scenario of teaching, training and capacity building programs in these areas. Against this background the present research was carried out to know the current teaching and training programs in public health engineering and related disciplines in India and to understand the potential opportunities and challenges available. A systematic, predefined approach was used to collect and assemble the data related to various teaching and training programs in public health engineering / environmental engineering in India. Public health engineering / environmental engineering education and training in the country is mainly offered through engineering institutions, as pre-service and in-service training. Pre-service programs include diploma, degree (graduate) and post-graduate courses affiliated to various state technical boards, institutes and universities, whereas in-service training is mainly provided by Government of India recognized engineering and public health training institutes. Though trainees of these programs acquire skills related to engineering sciences, they significantly lack in public health skills. The teaching and training of public health engineering / environmental engineering is limited as a part of public health programs (MD Community Medicine, MPH, DPH) in India. There is need for developing teaching and training of public health engineering or environmental engineering as an interdisciplinary subject. Public health institutes can play an important and significant role in this regard by engaging themselves in initiating specialized programs in this domain.

Objective medication adherence and persistence in people with multiple sclerosis: a systematic review, meta-analysis, and meta-regression.

BACKGROUND: Medication adherence is critical for the realization of pharmacotherapy benefits and reduced healthcare expenditure. Studies have shown up to 60% of people with Multiple sclerosis (MS) experience suboptimal medication adherence, which is associated with poorer health outcomes and subsequent discontinuation. The current systematic review reported on objectively measured adherence and discontinuation rates for self-administered oral and injectable disease-modifying therapies (DMTs). OBJECTIVES: To identify whether, in people with MS, the introduction of oral DMTs has improved medication adherence when compared with injectable DMTs. The secondary aim was to report synthesized objectively measured medication adherence and persistence rates for both oral and injectable DMTs in MS across varying study durations. METHODS: Literature searches were conducted through PubMed, Web of Science, Scopus, and PsycINFO. Inclusion criteria were limited to English, peer-reviewed, objective, self-administered DMT articles, published between July 1993 to December 2019. Publications reporting combined intravenous and self-administered DMT data, or that did not account for DMT switching in discontinuation rates, were excluded. Data were synthesized into observation lengths ranging from less than 8 months to greater than 36 months. Meta-analysis and meta-regression were undertaken on both oral and injectable 12-month adherence and discontinuation data. RESULTS: In total, 61 articles were included; 46 articles examined adherence and 26 examined discontinuation. Twelve-month adherence ranged between 53.0% to 89.2% for oral (N = 7) and 47.0% to 77.4% for injectable DMTs (N = 7). Results from the meta-analysis and meta-regression show significantly higher pooled mean medication possession ratio (MPR) adherence for oral DMTs (91.0%) when compared to injectable DMTs (77.0%) over 12 months (ß = -0.146; 95% CI: -0.263 to -0.029). Results indicate major asymmetry across studies (LFK index: -5.18), proposing the presence of significant publication bias. Mean discontinuation over 12 months was between 10.5% to 33.3% for oral (N = 7) and 15.2% to 50.8% for injectable DMTs (N = 10), with meta-analysis results indicating the presence of significant heterogeneity (I2 Injectable: 99.5%; I2 Oral: 93.1%) between studies included in each subgroup. However, no appreciable difference in mean discontinuation rates across groups (Injectable: 27%; 95% Cl: 19.0%-34.0%; Oral: 24%; 95% CI: 17.0%-31.0%) was found. CONCLUSIONS: Medication adherence for oral DMTs suggests a significant improvement compared to adherence for injectable DMTs. No significant difference in discontinuation rates between oral and injectable DMTs was found. Oral DMT adherence and persistence studies are limited, given their relatively recent introduction. Suboptimal medication adherence and discontinuation issues remain present for both oral and injectable DMTs. Future studies would benefit from improved consistency in methodology, such as comparable adherence and persistence definitions. DISCLOSURES: The authors did not receive any funding for this study. Mardan and Hussain have nothing to disclose. Grech reports grants from Merck Pharmaceutical, outside the submitted work. Allan reports grants received from Merck Pharmaceutical outside the submitted work. Allan holds advisory board and consulting positions with Merck and advisory board positions for Bristol Myers Squibb and Novartis, for which Monash Institute of Neurological Diseases receives consulting fees.

Estimating the relative contribution of comorbidities in predicting health-related quality of life of people with multiple sclerosis.

BACKGROUND: Little is known about the relative contribution of comorbidities in predicting the health-related quality of life (HRQoL) of people with Multiple Sclerosis (PwMS). OBJECTIVE: To determine the associations between the number of and individual comorbidities and HRQoL and estimate the relative contribution of different comorbidities on HRQoL. METHODS: Cross-sectional analysis of data on self-reported presence of 30 comorbidities and HRQoL from the Australian MS Longitudinal Study (AMSLS) participants (n = 902). HRQoL was measured using the Assessment of Quality of Life-8 Dimensions (AQoL-8D). Linear regression and general dominance analysis were used. RESULTS: Higher number of comorbidities was associated with lower HRQoL (p trend p < 0.01). Comorbidities accounted for 18.1% of the variance in HRQoL. Mental health and musculoskeletal disorders were the strongest contributors to lower HRQoL. Of individual comorbidities, systemic lupus erythematosus (SLE) [ß = - 0.16 (- 0.27, - 0.05)] and depression [ß = - 0.15(- 0.18, - 0.13)] were most strongly associated with overall HRQoL, depression [ß = - 0.14(- 0.16, - 0.11)] and anxiety [ß = - 0.10 (- 0.13, - 0.07)] with psychosocial HRQoL, and SLE [ß = - 0.18 (- 0.29, - 0.07)], rheumatoid arthritis [ß = - 0.11 (- 0.19, - 0.02)] and hyperthyroidism [ß = - 0.11 (- 0.19, - 0.03)) with physical HRQoL. CONCLUSION: Comorbidities potentially make important contributions to HRQoL in PwMS. Our findings highlight groups of and individual comorbidities that could provide the largest benefits for the HRQoL of PwMS if they were targeted for prevention, early detection, and optimal treatment.

Multimorbidity and Its Outcomes Among Patients Attending Psychiatric Care Settings: An Observational Study From Odisha, India.

Background: Multimorbidity, the presence of two or more chronic health conditions is linked to premature mortality among psychiatric patients since the presence of one can further complicate the management of either. Little research has focused on the magnitude and effect of multimorbidity among psychiatric patients in low-and middle-income settings. Our study, provides the first ever data on multimorbidity and its outcomes among patients attending psychiatric clinics in Odisha, India. It further explored whether multimorbidity was associated with higher medical expenditure and the interaction effect of psychiatric illness on this association. Methods: This cross-sectional study included 500 adult patients presenting to the psychiatric clinic of a medical college hospital in Odisha over a period of 6 months (February 2019-July 2019). A validated structured questionnaire, "multimorbidity assessment questionnaire for psychiatric care" (MAQ-PsyC) was used for data collection. We used multinomial logistic model for the effect estimation. Odds ratios (OR) and 95% confidence intervals (CI) for high healthcare utilization and expenditure were calculated by number and pattern of multimorbidity. Data was analyzed by STATA 14. Results: Half (50%) of the psychiatric outpatients had multimorbidity. The relative probabilities of having one additional condition were 5.3 times (RRR = 5.3; 95% CI: 2.3, 11.9) and multiple morbidities were 6.6 times (RRR = 6.6; 95%CI: 3.3, 13.1) higher for patients in 60+ age group. Healthcare utilization i.e., medication use and physician consultation was significantly higher for psychiatric conditions such as mood disorders, schizophrenia, schizotypal and delusional disorders, and for hypertension, cancer, diabetes, among somatic conditions. Out of pocket expenditure (OOPE) was found to be highest for laboratory investigations, followed by medicines and transport expenditure. Within psychiatric conditions, mood disorders incurred highest OOPE ($93.43) while hypertension was the most leading for OOPE in physical morbidities ($93.43). Psychiatric illnesses had a significant interaction effect on the association between multimorbidity and high medical expenditure (P = 0.001). Conclusion: Multimorbidity is highly prevalent in psychiatric patients associated with significantly high healthcare utilization and medical expenditure. Such disproportionate effect of psychiatric multimorbidity on healthcare cost and use insinuates the need for stronger financial protection and tailor-made clinical decision making for these vulnerable patient subgroups.

Challenges in Managing Acute Cardiovascular Diseases and Follow Up Care in Rural Areas: A Narrative Review.

This narrative review explores relevant literature that is related to the challenges in implementing evidence-based management for clinicians in rural and remote areas, while primarily focussing on management of acute coronary syndrome (ACS) and follow up care. A targeted literature search around rural/urban differences in the management of ACS, cardiovascular disease, and cardiac rehabilitation identified multiple issues that are related to access, including the ability to pay, transport and geographic distances, delays in patients seeking care, access to diagnostic testing, and timely treatment in an appropriate facility. Workforce shortages or lack of ready access to relevant expertise, cultural differences, and complexity that arises from comorbidities and from geographical isolation amplified diagnostic challenges. Given the urgency in management of ACS, rural clinicians must act quickly to achieve optimal patient outcomes. New technologies and quality improvement approaches enable better access to rapid diagnosis, as well as specialist input and care. Achieving an uptake of cardiac rehabilitation in rural and remote settings poses challenges that may reduce with the use of alternative models to centre-based rehabilitation and use of modern technologies. Expediting improvement in cardiovascular outcomes and reducing rural disparities requires system changes and that clinicians embrace attention to prevention, emergency management, and follow up care in rural contexts.

A Pragmatic Review to Assist Planning and Practice in Delivering Nutrition Education to Indigenous Youth.

Many health promotion campaigns have incorporated multi-component nutrition interventions to promote healthy diet-related behaviours among Indigenous communities, particularly children and adolescents. However, these campaigns show mixed results and while research often describes outcomes of approaches and interventions, it does not extensively describe implementation processes and best practices for nutrition education for Indigenous youth. To enhance knowledge and understanding of best processes in nutritional education approaches with Indigenous youth, we conducted a search using multiple databases including PubMed, Google Scholar, the Australian Indigenous HealthInfoNet and Australian government research databases to identify relevant peer-reviewed and grey literature as well as educational resources, such as websites and handbooks for teachers, parents, and students. We list and describe common features of successful nutritional interventions in Indigenous settings, steps for nutrition education targeting youth, school-based nutrition education for different ages, and general guidelines for teaching Indigenous students. Current best practice and knowledge gaps for the delivery of nutrition education to Indigenous youth are described.

Real-world efficacy and toxicity of combined nivolumab and ipilimumab in patients with metastatic melanoma.

BACKGROUND: There is limited real-world data on the efficacy and safety of combination programmed cell death protein-1 (PD-1) inhibitor, nivolumab and the cytotoxic T-lymphocyte antigen (CTLA-4) inhibitor ipilimumab. METHOD: We retrospectively identified patients (pts) with metastatic melanoma treated with three-weekly nivolumab (1 mg/kg) in combination with ipilimumab (3 mg/kg) for four cycles followed by nivolumab monotherapy (3 mg/kg) fortnightly. Patient demographics and treatment parameters were collected and outcomes determined. RESULTS: A total of 45 pts received combination treatment with a median follow up of 8.7 months (range 0.33-25.9 months). A total of 67% were male, and BRAF V600 mutations detected in 38%. At treatment commencement, 14 (31%) pts had brain metastases, 51% had an elevated LDH and 18 (40%) were treatment-naive. Almost a third (30%) required corticosteroids for symptom control or management of prior toxicities. Nineteen (42%) patients had prior anti-PD-1 therapy. The disease control rate (DCR) was 54% and objective response rate (ORR) was 29%. Of pts treated with prior immune checkpoint inhibitors, the DCR and ORR were 50% and 33%, respectively. Intracranial responses were observed in 18% (n = 2). The median progression-free survival (PFS) was 5.8 months (95% Confidence interval (CI), 2.9-14.1 months). PFS was higher in treatment naïve patients compared to those who had prior immunotherapy (6.2 months vs 4.9 months, P = 0.59). The median OS was 17.4 months (95% CI, 7.1-NR). pts requiring corticosteroids had a shorter PFS (4.9 months vs 6.8 months) and OS (7.1 months vs NR, P = 0.01).Treatment-related adverse events of any grade were experienced by 88% of pts, with 54% having grade 3-4 adverse events. Treatment discontinuation due to adverse events occurred in 44% of pts. CONCLUSION: In this study, responses to combination immunotherapy were lower than reported. Patients treated with prior immunotherapy had similar responses as treatment-naïve pts. The toxicity profile seen in this study is similar to those reported in clinical trials.

Complexity in disease management: A linked data analysis of multimorbidity in Aboriginal and non-Aboriginal patients hospitalised with atherothrombotic disease in Western Australia.

BACKGROUND: Hospitalisation for atherothrombotic disease (ATD) is expected to rise in coming decades. However, increasingly, associated comorbidities impose challenges in managing patients and deciding appropriate secondary prevention. We investigated the prevalence and pattern of multimorbidity (presence of two or more chronic conditions) in Aboriginal and non-Aboriginal Western Australian residents with ATDs. METHODS AND FINDINGS: We used population-based de-identified linked administrative health data from 1 January 2000 to 30 June 2014 to identify a cohort of patients aged 25-59 years admitted to Western Australian hospitals with a discharge diagnosis of ATD. The prevalence of common chronic diseases in these patients was estimated and the patterns of comorbidities and multimorbidities empirically explored using two different approaches: identification of the most commonly occurring pairs and triplets of comorbid diseases, and through latent class analysis (LCA). Half of the cohort had multimorbidity, although this was much higher in Aboriginal people (Aboriginal: 79.2% vs. non-Aboriginal: 39.3%). Only a quarter were without any documented comorbidities. Hypertension, diabetes, alcohol abuse disorders and acid peptic diseases were the leading comorbidities in the major comorbid combinations across both Aboriginal and non-Aboriginal cohorts. The LCA identified four and six distinct clinically meaningful classes of multimorbidity for Aboriginal and non-Aboriginal patients, respectively. Out of the six groups in non-Aboriginal patients, four were similar to the groups identified in Aboriginal patients. The largest proportion of patients (33% in Aboriginal and 66% in non-Aboriginal) was assigned to the "minimally diseased" (or relatively healthy) group, with most patients having less than two conditions. Other groups showed variability in degree and pattern of multimorbidity. CONCLUSION: Multimorbidity is common in ATD patients and the comorbidities tend to interact and cluster together. Physicians need to consider these in their clinical practice. Different treatment and secondary prevention strategies are likely to be useful for management in these cluster groups.

Prevalence, Pattern, and Correlates of Alcohol Misuse among Male Patients Attending Rural Primary Care in India.

BACKGROUND: There are limited data available on how the problem of alcohol use is detected in primary care setting in India. Particularly in Odisha, it has not been investigated yet. This study was conducted to determine the prevalence of drinking, drinking patterns, and quitting behavior among the male patients visiting a primary health-care facility in a district of Odisha. METHODOLOGY: A cross-sectional study was conducted among patients attending community health center (CHC), Buguda in the state of Odisha, India, from December 1, 2014, to February 31, 2015. Patients above 18 years of age, conscious, and willing to participate in the study were included in the study, while those with cognitive impairment and critically ill were excluded from the study. All eligible consecutive patients attending outpatient department of CHC were invited to participate while they came out after physician's consultation. A pilot study was conducted prior to the study. Informed verbal consent from each patient was obtained before the interview. The study was approved by the Institutional Ethics Committee of Indian Institute of Public Health, Bhubaneswar. RESULTS: A total of 431 patients were interviewed. Our study showed 38% (95% confidence interval [CI]: 33.5%-42.7%) of respondents were alcoholic and of those 60% (95% CI: 51.4%-66.5%) were hazardous drinkers. One in five patients had a history of alcoholics in their family, and a similar proportion of participants were heavy workers. Smokers were eight times (adjusted odds ratio [AOR] =7.56; 4.03-14.52) more likely to be alcoholics as compared to nonsmokers (P < 0.001), whereas the prevalence of alcohol drinking was four times (AOR = 3.94; 2.25-6.92) higher in smokeless tobacco users compared to nonusers. CONCLUSION: Focusing only on counseling and treatment services will not reduce the piling burden of alcohol use. It is important to target the environment that leads to such habits.