ABSTRACT
Aims: At our Trust, all severe inpatient hypoglycaemic episodes in individuals with diabetes (defined as a hypoglycaemic episode requiring injectable treatment) are reported to NaDIA-Harms (National Diabetes Inpatient Audit). We conducted a detailed review of the care of all these events to improve patient safety. In this study, we assessed the risk of 12-month mortality following an episode of severe inpatient hypoglycaemia. Method(s): Reportable NaDIA harms of patients admitted during the period 2018-2022 were recorded into a dataset. Applicable patient records were reviewed at 12 months following the event to see how many patients were deceased and details of comorbidities at the time of the severe hypoglycaemic episode were collected. Result(s): To date, of 107 inpatients who experienced a severe hypoglycaemic episode 55% were deceased within 12 months. In patients admitted during the peak of the Covid-19 pandemic recorded as year April 2020/March 2021, 80% of patients who had a NaDIA hypoglycaemic event died within 12 months. Conclusion(s): Mortality rate following an episode of inpatient hypoglycaemia appears to be several-fold higher than previous reported rates of 4.45%-22.1% for community-dwelling individuals who experience a severe hypoglycaemic event. This maybe partially explained by the increased frailty, polypharmacy and multimorbidity among this cohort, but there is evidence linking hypoglycaemia with cardiovascular mortality. Although no causality between severe inpatient hypoglycaemia and death can be inferred from this study because of the observational nature, it does highlight the importance preventing inpatient episodes of hypoglycaemia through effective monitoring and proactive treatment modification.
ABSTRACT
Background: Patients with systemic lupus erythematosus (SLE) are at an increased risk of infection relative to the general population. We aimed to describe the frequency and risk factors for serious infections in patients with moderate-to-severe SLE treated with rituximab, belimumab, and standard of care therapies in a large national observational cohort. Method(s): The British Isles Lupus Assessment Group Biologics Register (BILAG-BR) is a UK-based prospective register of patients with SLE. Patients were recruited by their treating physician as part of their scheduled care from 64 centres across the UK by use of a standardised case report form. Inclusion criteria for the BILAG-BR included age older than 5 years, ability to provide informed consent, a diagnosis of SLE, and starting a new biological therapy within the last 12 months or a new standard of care drug within the last month. The primary outcome for this study was the rate of serious infections within the first 12 months of therapy. Serious infections were defined as those requiring intravenous antibiotic treatment, hospital admission, or resulting in morbidity or death. Infection and mortality data were collected from study centres and further mortality data were collected from the UK Office for National Statistics. The relationship between serious infection and drug type was analysed using a multiple-failure Cox proportional hazards model. Finding(s): Between July 1, 2010, and Feb 23, 2021, 1383 individuals were recruited to the BILAG-BR. 335 patients were excluded from this analysis. The remaining 1048 participants contributed 1002.7 person-years of follow-up and included 746 (71%) participants on rituximab, 119 (11%) participants on belimumab, and 183 (17%) participants on standard of care. The median age of the cohort was 39 years (IQR 30-50), 942 (90%) of 1048 patients were women and 106 (10%) were men. Of the patients with available ethnicity data, 514 (56%) of 911 were White, 169 (19%) were Asian, 161 (18%) were Black, and 67 (7%) were of multiple-mixed or other ethnic backgrounds. 118 serious infections occurred in 76 individuals during the 12-month study period, which included 92 serious infections in 58 individuals on rituximab, eight serious infections in five individuals receiving belimumab, and 18 serious infections in 13 individuals on standard of care. The overall crude incidence rate of serious infection was 117.7 (95% CI 98.3-141.0) per 1000 person-years. Compared with standard of care, the serious infection risk was similar in the rituximab (adjusted hazard ratio [HR] 1.68 [0.60-4.68]) and belimumab groups (1.01 [0.21-4.80]). Across the whole cohort in multivariate analysis, serious infection risk was associated with prednisolone dose (>10 mg;2.38 [95%CI 1.47-3.84]), hypogammaglobulinaemia (<6 g/L;2.16 [1.38-3.37]), and multimorbidity (1.45 [1.17-1.80]). Additional concomitant immunosuppressive use appeared to be associated with a reduced risk (0.60 [0.41-0.90]). We found no significant safety signals regarding atypical infections. Six infection-related deaths occurred at a median of 121 days (IQR 60-151) days from cohort entry. Interpretation(s): In patients with moderate-to-severe SLE, rituximab, belimumab, and standard immunosuppressive therapy have similar serious infection risks. Key risk factors for serious infections included multimorbidity, hypogammaglobulinaemia, and increased glucocorticoid doses. When considering the risk of serious infection, we propose that immunosupppressives, rituximab, and belimumab should be prioritised as mainstay therapies to optimise SLE management and support proactive minimisation of glucocorticoid use. Funding(s): None.Copyright © 2023 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license
ABSTRACT
Background: Idiopathic inflammatory myopathies are a group of rare systemic autoimmune rheumatic diseases with substantial heterogeneity. We aimed to investigate gender differences in patient-reported outcomes and treatment regimens of people with idiopathic inflammatory myopathies. Method(s): This international, patient-reported, e-survey was conducted worldwide. We used data from the COVID-19 vaccination in autoimmune disease (COVAD) study, a large-scale, international, self-reported e-survey assessing the safety of COVID-19 vaccination in patients older than 18 years with autoimmune rheumatic diseases, including idiopathic inflammatory myopathies. The COVAD study was conducted in more than 80 health-care centres, including hospitals, clinics, and universities located in more than 50 countries worldwide and on social media platforms, such as Facebook and Twitter. The COVAD e-survey was open between April 1, 2021, and Dec 31, 2021. We extracted survey data regarding demographics;autoimmune rheumatic disease diagnosis;autoimmune multimorbidity (three or more autoimmune rheumatic disease diagnoses for each patient);current corticosteroid or immunosuppressant use;and patient-reported outcomes, including fatigue and pain Visual Analogue Scale (VAS), and PROMIS short form-physical function 10a (PF-10a). Gender was reported by participants with three options (men, women, or do not wish to disclose). Patient-reported outcomes and corticosteroid or immunosuppressant use were compared between men and women. Participants with inclusion body myositis were analysed separately due to the substantial difference in treatment and disease outcomes compared with other idiopathic inflammatory myopathy subtypes. Factors affecting each patient-reported outcome were determined using multivariable analysis. Finding(s): The survey data were extracted on Aug 31, 2021, and 1202 complete responses from participants with idiopathic inflammatory myopathies were analysed. Five patients who did not wish to disclose gender were excluded. 845 (70.6%) of the remaining 1197 were women. Women were younger than men (median 58 years [IQR 48-68] vs 69 years [58-75];p=0.00010). Autoimmune multimorbidity was more common in women than in men (94 [11.1%] of 845 vs 11 [3.1%] of 352;p<0.0001). Corticosteroid use was similar in men and women with idiopathic inflammatory myopathies (except for inclusion body myositis), whereas the distribution of immunosuppressants was different, with higher hydroxychloroquine use in women (131 [18.3%] of 717 vs 11 [6.9%] of 159 in men;p=0.0082). The median fatigue VAS was significantly higher in women than in men (5 [IQR 3-7] vs 4 [2-6];p=0.0036), whereas the gender difference in pain VAS (median 3 [IQR 1-5] in women vs 2 [0-4] in men;p=0.064) and PROMIS PF-10a scores (38 [31-45] vs 39 [30-47];p=0.29) was non-significant. There were no significant differences in patient-reported outcomes and treatment in participants with inclusion body myositis. The multivariable analysis of idiopathic inflammatory myopathies (except for inclusion body myositis) revealed that female sex, residence in high-income countries, a diagnosis of overlap myositis, and autoimmune multimorbidity were independent risk factors for higher fatigue VAS. Interpretation(s): Women with Idiopathic inflammatory myopathies frequently have autoimmune multimorbidity and increased fatigue compared with men, calling for greater attention and further research on targeted treatment approaches. Funding(s): None.Copyright © 2022 Elsevier Ltd
ABSTRACT
Introduction: The Czech Republic (CR) is a country with the high mortality due to COVID-19 from a global perspective. Despite its robustness, the health care system was overloaded several times. Aim(s): We want to find out which factors were associated with the risk of severe covid (SC, ie ICU stay or death) in the population of the CR. Method(s): The whole population analysis was based on data (related to all-cause mortality, hospitalization/intensive care, comorbidity burden-CCI, age/gender) collected by the Institute of Health Information and Statistics of the CR via the National Health Information System. Multivariate logistic regression was used to evaluate the influence of interest parameters. Result(s): We analysed data of 153.783 patients (pts) aged 40+ hospitalized due to primoinfection and had valid data (average 71yrs;52 % males). 30.502 (19.8 %) pts stayed at ICU. Every fourth (35.746;23.2 %) hospitalized patient died. Females (OR 0.66), and >80yrs (OR 0.56) had lower probability to be hospitalized in the ICU than males and pts 40-49 yrs. Comorbid burden (CCI 1;2;3-4;5 and more) was associated with a slight increase (OR 1.10;1.18;1.23;1.14) in the likelihood of being hospitalized in the ICU. Females (OR 0.63) had lower probability to SC. Contrary increased age (50-59;60-69;70-79;>80), respectively higher CCI (1;2;3-4;5 and more) were associated with strong rise (OR 1.29;1.67;1.93;2.48) resp. (OR 1.14;1.30;1.50;1.90) of SC risk. Conclusion(s): Older age, multimorbidities are associated with a strong probability of SC, however, the level of care at the ICU does not fully correspond to this.
ABSTRACT
Objective: The primary objective was to explore indications for inpatient glucose telemetry. Method(s): The inpatient glucose telemetry (IGT) has been instituted at the peak of COVID cases at an urban academic medical center. Besides remote glucose monitoring due to infection isolation, feasibility, reliability and indications for IGT were investigated in hospitalized patients. Result(s): IGT was used in n=75 patients in critical and non-critical care inpatient settings. In addition to remote glucose monitoring due to infection isolation, feasibility, reliability and indications for IGT were investigated in cases requiring hypoglycemia prevention, multimorbidity, fingertip bruising, transplant, cancer, intensive insulin management, brain/psychiatric disease/injury, and inpatient rehabilitation.IGT was used in patients hospitalized with personal home continuous glucose monitoring system and patients with recurrent diabetes hospitalizations. Conclusion(s): Inpatient glucose telemetry indications must be expanded beyond hypoglycemia prevention.
ABSTRACT
Background and Aim: This study aimed to understand the impact of breathlessness on quality of life, productivity loss and healthcare use of Australian adults. Method(s): The National Breathlessness Survey was a nationwide cross-sectional web-based survey in Oct 2019, recruiting Australians aged >=18 years stratified by age-group, gender and state of residence. Severity of breathlessness using the modified Medical Research Council (mMRC) dyspnoea scale (0-5), quality of life (QoL) using EQ-VAS and EQ-5D-5L, and healthcare use (HCU) and productivity loss associated with having a "breathing problem" in the past 12 months were analysed. Quintile regression was conducted to analyse QoL and binary logistic regression for HCU and productivity loss outcomes. Effect sizes were adjusted for age, gender, Indigenous background, self-reported heart and lung disease, high PHQ-4 score, multimorbidity and smoking. Result(s): 10,072 adults completed the survey. The prevalence of clinically important breathlessness (mMRC>=2) was 9.54%. mMRC>=2 was associated with worse QoL, and greater healthcare use and productivity loss compared with mMRC=1 (Table). Despite COVID-19 impacts, similar prevalence (8.15%) and associations were seen in a repeat cross-sectional survey in December 2020 (n=10,024). Conclusion(s): Breathlessness carries a significant burden for patients, the healthcare system, and the economy.
ABSTRACT
The 2021 Conference on Retroviruses and Opportunistic Infections (CROI) featured a timely review of the neurologic complications of COVID-19 as well as new research findings on mechanisms by which SARS-CoV-2 may affect the brain. CROI included new and important findings about the neurologic complications of HIV-1, human polyomavirus 2 (also known as JC Virus), and cryptococcus. New long-term analyses of cognition in people with HIV-1 identified that cognitive decline over time is associated with multimorbidity, particularly diabetes, chronic lung disease, and vascular disease risk conditions. These conditions are associated with aging, and the question of whether people with HIV are at risk for premature aging was addressed by several reports. New findings from large analyses of resting state networks also provided valuable information on the structural and functional networks that are affected by HIV-1 infection and cognitive impairment. Several reports addressed changes after initiating or switching antiretroviral therapy (ART). Findings that will improve understanding of the biologic mechanisms of brain injury in people with HIV were also presented and included evidence that host (eg, myeloid activation, inflammation, and endothelial activation) and viral (eg, transcriptional activity and compartmentalization) factors adversely affect brain health. Other research focused on adjunctive therapies to treat HIV-1 and its complications in the central nervous system. This summary will review these and other findings in greater detail and identify key gaps and opportunities for researchers and clinicians.Copyright © 2021, IAS-USA. All rights reserved.
ABSTRACT
Aging increases susceptibility to medical and psychiatric comorbidity via interrelated biological, psychological, and social mechanisms. Mental status changes or other psychiatric symptoms occurring in older adults with medical disorders most often result from delirium, depression, or the onset of Alzheimer's disease and related dementias (ADRD). Clinicians can use evidence-based tools to evaluate such symptoms including the 4A's Test for delirium, the Saint Louis University Mental Status Exam, and the Geriatric Depression Scale. Innovative models such as collaborative care can improve the outcome of care of older adults with medical disorders requiring treatment for depression or ADRD..
Subject(s)
Alzheimer Disease , Delirium , Humans , Aged , Comorbidity , Delirium/diagnosisABSTRACT
Introduction: COVID-19 policies such as quarantining, social isolation, and lockdowns are an essential public health measure to reduce the spread of disease but may lead to reduced physical activity. Little is known if these changes are associated with changes in physical or mental health. Method(s): Between September 2017 and December 2018 (baseline) and March 2020 and February 2021 (follow-up), we obtained self-reported demographic, health, and walking (only at follow-up) data on 2042 adults in primary care with multiple chronic health conditions. We examined whether the perceived amount of time engaged in walking was different compared with prepandemic levels and if this was associated with changes in Patient-Reported Outcomes Measurement Information System-29 mental and physical health summary scores. Multivariable linear regression controlling for demographic, health, and neighborhood information were used to assess this association. Result(s): Of the 2042 participants, 9% reported more walking, 28% reported less, and 52% reported the same amount compared with prepandemic levels. Nearly 1/3 of participants reported less walking during the pandemic. Multivariable models revealed that walking less or not at all was associated with negative changes in mental (s = -1.0;95% CI [-1.6, -0.5];s = -2.2;95% CI [-2.9, -1.4]) and physical (s = -0.9;95% CI [-1.5, -0.3];s = -3.1;95% CI [-4.0, -2.3]) health, respectively. Increasing walking was significantly associated with a positive change in physical health (s = 1.3;95% CI [0.3, 2.2]). Conclusion(s): These findings demonstrate the importance of walking during the COVID-19 pandemic. Promotion of physical activity should be taken into consideration when mandating restrictions to slow the spread of disease. Primary care providers can assess patient's walking patterns and implement brief interventions to help patients improve their physical and mental health through walking. Copyright © 2022 American Board of Family Medicine. All rights reserved.
ABSTRACT
Background/Purpose: Idiopathic inflammatory myopathies (IIMs) are a group of rare systemic autoimmune rheumatic diseases (AIRDs) with considerable heterogeneity. Little is reported about gender difference in patient-reported outcomes (PROs) of those with IIMs, which have a significant impact on health-related quality of life. We aimed to investigate the gender difference in PROs and treatment regimens of IIM patients utilizing data obtained in the COVID-19 vaccination in autoimmune disease (COVAD) study, a large-scale, international self-reported e-survey assessing the safety of COVID-19 vaccination in patients with various AIRDs including IIMs. Method(s): The COVAD study was launched in April 2021 and continued until December 31, 2021. The survey data regarding demographics, AIRD diagnosis, autoimmune multimorbidity (defined as three or more AIRD diagnoses for each patient), disease activity, current corticosteroid or immunosuppressant use, and PROs including fatigue and pain VAS, PROMIS Short Form -Physical Function 10a (PROMIS PF-10a), general health status, and ability to carry out routine activities were extracted from the COVAD database. Each PRO, disease activity, and treatments were compared between women and men. Patients with inclusion body myositis (IBM) were analyzed separately due to significant difference in treatment regimens and outcomes compared to other IIM subtypes. Factors affecting each PRO were determined by multivariable analysis. Result(s): 1197 complete responses from IIM patients as of August 2021 were analyzed. 845 (70.6%) patients were women. Women were younger (58 [48-68] vs. 69 [58-75] years old, median [interquartile range (IQR)], P0.001), and more likely to suffer from autoimmune multimorbidity compared to men (11.1% vs. 3.1%, P 0.001;Table 1). In patients with non-IBM IIMs, disease activity and corticosteroid use were comparable in both genders, while the distribution of immunosuppressant use was different (P = 0.002), with more hydroxychloroquine use in women (18.3% vs. 6.9%). The median fatigue VAS was significantly higher in women than in men (5 [IQR 3-7] vs. 4 [IQR 2-6], P = 0.004), whereas gender difference in the other PROs was not statistically significant (Table 2). In patients with IBM, on the other hand, no significant gender differences in PROs and treatment regimens were observed. The multivariable analysis in non-IBM IIMs revealed women, living in high-income countries, overlap myositis, and autoimmune multimorbidity as independent factors for higher fatigue VAS. Conclusion(s): Women with IIMs frequently suffer from autoimmune multimorbidity, and also experience more fatigue compared to men, calling for greater attention and further research on targeted treatment approaches. (Table Presented).
ABSTRACT
Background: COVID-19 vaccines are safe & effective, though patients with rheumatic diseases like idiopathic inflammatory myositis (IIMs), and those with multiple comorbidities continue to be hesitant. Adverse events after vaccination are not extensively studied in those with multiple coexisting autoimmune diseases. Patients with IIM often have multiple autoimmune rheumatic and autoimmune non-rheumatic comorbidities (IIM-AIDs), with potentially increased risk of AEs. The COVAD study aimed to assess COVID-19 vaccination-related AEs till 7 days post-vaccination in IIM-AIDs compared to IIMs and healthy controls (HCs) group. Method(s): T he C OVAD s tudy g roup c omprised > 110 c ollaborators across 94 countries. The study was conducted from March-December 2021. A survey monkey platform-based self-reported online survey captured data related to COVID-19 vaccination-related AEs in IIMs, AIDs, and HCs. We compared COVID-19 vaccination-related AEs among IIM-AID patients and IIM alone and HCs, adjusting for age, gender, ethnicity, vaccine type, immunosuppression, and numbers of AIDs, using binary logistic regression. Statistically significant results following multivariate regression are reported. Result(s): Among 6099 participants, 1387 (22.7%) IIM, 4712 (77.2%) HC, 66.3% females, were included from 18 882 respondents: 573 (41.0%) people with IIM-AIDs;814 (59.0%) with IIM without other AIDs;and 4712 HCs. People with IIM were older [median 54 (45-66) IIM-AIDs, 64 (50-73) IIM, 34 (26-47) HC years, P < 0.001]. BNT162b2 (Pfizer) (37.5%) and ChAdOx1nCoV-19 (Oxford) (11.1%) were the most common vaccines. When compared to IIM alone, IIM-AID patients reported higher overall AEs [OR 1.5 (1.1-2.1)], minor AE [OR 1.5 (1.1-2.1)] &major AE [OR 3 (1.5-5.8)]. IIM-AIDs patients also reported higher body ache, nausea, headache, & fatigue (OR ranging 1.3-2.3). After adjusting for the number of AIDs, the major AEs equalized but overall AEs, & minor AEs, such as fatigue remained higher. When compared to HCs, IIM-AIDs patients reported similar overall AEs, minor AEs but higher major AEs [OR 2 (1.2-3.3)] nausea/ vomiting [OR 1.4 (1.01-2)], headache [OR 1.2 (1.01-1.6)], and fatigue [OR 1.3 (1.03-1.6)]. Dermatomyositis with AIDs (n = 183) reported higher major AEs [OR 4.3 (1.5-12)] compared to DM alone (n = 293). Active IIM with AIDs (n = 482) reported higher overall AEs [OR 1.5 (1.1-2.2)], minor AEs [OR 1.5 (1.1-2.2)] and major AEs [OR 2.6 (1.2-5.2)] compared to active IIM alone (n = 643). Conclusion(s): COVID-19 vaccination is safe with minimal to no risks of short-term AEs in patients with IIM without other concomitant autoimmune diseases. The presence of autoimmune multimorbidity conferred higher self-reported short-term risks of overall, major, and minor COVID-19 vaccination-related AEs 7 days post-vaccination, particularly in those with active IIM.
ABSTRACT
Primary care must face the new challenges of the XXI century that have already started with the Covid-19 pandemic. These challenges have to do with a new sociosanitary reality characterized by a rise of the prevalence of the comorbidity and fragility linked to the eldering and the impact of the determinants of the health. Changes in the population, one with more informed patients who demand participating in the decisions that affect their health in a society that is increasingly digitalized. In this context the primary care must solve its challenges such as changing its way of functioning in more cohesive teams that can incorporate new profiles that are really needed and that bring value and where a compromise with teaching and investigation exists. The management of these challenges requires that the professionals working in primary care in the XXI century deepen in their competences looking further than the limits of their health centres. Competences such as the selection and use of the best knowledge, the critical thought, the use of communication to approach to the values and preferences of their patients, the shared decision making and social conscience. In order to these changes to pursue, an institutional impulse is necessary, one with the, many times insistently claimed by the professionals, measures. Among which is, firstly, a bigger inversion in personnel and equipment as well as the commitment with evidently proved models intended to obtain a more coordinated and integrated attention between the primary care, the hospital, the mental health, the public health and the social services, the judicious use of the e-health solutions or the incorporation of a knowledge area of primary care in the University. Copyright © 2022 The Author(s)
ABSTRACT
Background: Multimorbidity is most prevalent in older adults and is associated with higher symptom burden, lower quality of life, increased functional decline, and caregiver burden that warrants holistic intervention. Continued rise in the prevalence of multimorbidity is expected, especially among older adults. The COVID-19 pandemic required that a co-design event with patients, family caregivers, and health care providers discussing their preferences surrounding multimorbidity management be virtual. Objective(s): To discuss the challenges of organizing a virtual co-design event. Method(s): A virtual co-design event was held using Health Insurance Portability and Accountability Act-compliant Zoom technology. Patients (age 55 or older and living with multimorbidity), family caregivers, and health care providers interviewed in a prior phase of the project were invited to the codesign event. Data regarding participants' disease trajectory and improvement priorities were collected. The experiences of the study team, including event facilitators, were used to identify challenges and opportunities. Result(s): Four male patients, two female health care providers, and seven facilitators participated in the event. Five improvement priorities were identified: (1) patient-provider relationship, (2) communication, (3) availability of resources, (4) caregiver support, and (5) care coordination and follow-up. Conclusion(s): Virtual events could be a valuable tool to get diverse groups of participants to provide input;however, the recruitment process and the technological literacy of some older adults pose challenges. Using a virtual platform requires consideration of participants' access to technology, their technological literacy, the use of innovative human-centered design, and the need for holding multiple events to yield comprehensive data. Recruiting more diverse groups of participants-e.g., groups that include family caregivers and female patients-is critical, as they may present different needs and outcomes..
ABSTRACT
Objectives: First impact assessment analysis of an integrated care model (ICM) to reduce hospital activity in the London Borough of Hillingdon, UK. Methods: We evaluated a population-based ICM consisting of multiple interventions based on self-management, multidisciplinary teams, case management and discharge management. The sample included 331 330 registered Hillingdon residents (at the time of data extraction) between October 2018 and July 2020. Longitudinal data was extracted from the Whole Systems Integrated Care database. Interrupted time series Poisson and Negative binomial regressions were used to examine changes in non-elective hospital admissions (NEL admissions), accident and emergency visits (A&E) and length of stay (LoS) at the hospital. Multiple imputations were used to replace missing data. Subgroup analysis of various groups with and without long-term conditions (LTC) was also conducted using the same models. Results: In the whole registered population of Hillingdon at the time of data collection, gradual decline over time in NEL admissions (RR 0.91, 95% CI 0.90 to 0.92), A&E visits (RR 0.94, 95% CI 0.93 to 0.95) and LoS (RR 0.93, 95% CI 0.92 to 0.94) following an immediate increase during the first months of implementation in the three outcomes was observed. Subgroup analysis across different groups, including those with and without LTCs, showed similar effects. Sensitivity analysis did not show a notable change compared with the original analysis. Conclusion: The Hillingdon ICM showed effectiveness in reducing NEL admissions, A&E visits and LoS. However, further investigations and analyses could confirm the results of this study and rule out the potential effects of some confounding events, such as the emergence of COVID-19 pandemic.
ABSTRACT
PURPOSE: Many patients delayed health care during COVID-19. We assessed the extent to which patients managing multiple chronic conditions (MCC) delayed care in the first months of the pandemic, reasons for delay, and impact of delay on patient-reported physical and behavioral health (BH) outcomes. METHODS: As part of a large clinical trial conducted April 2016-June, 2021, primary care patients managing MCC were surveyed about physical and behavioral symptoms and functioning. Surveys administered between September 3, 2020, and March 16, 2021, included questions about the extent of and reasons for any delayed medical and BH care since COVID-19. Multivariable linear regression was used to assess health outcomes as a function of delay of care status. RESULTS: Among patients who delayed medical care, 58% delayed more than once. Among those who delayed behavioral health care, 63% delayed more than once. Participants who delayed multiple times tended to be younger, female, unmarried, and reported food, financial, and housing insecurities and worse health. The primary reasons for delaying care were lack of availability of in-person visits and perceived lack of urgency. Participants who delayed care multiple times had significantly worse outcomes on nearly every measure of physical and mental health, compared with participants who delayed care once or did not delay. CONCLUSIONS: Delay of care was substantial. Patients who delayed care multiple times were in poorer health and thus in need of more care. Effective strategies for reengaging patients in deferred care should be identified and implemented on multiple levels. TRIAL REGISTRATION: ClinicalTrials.gov NCT02868983. Registered on August 16, 2016.
ABSTRACT
OBJECTIVE: Determine characteristics of Medicare beneficiaries with diabetes and multiple chronic conditions (MCC) associated with being unable to obtain medical services during COVID-19. RESEARCH DESIGN AND METHODS: Retrospective cohort study of data from COVID-19 Supplements of Medicare Current Beneficiary Surveys administered in Summer (N = 11,114, unweighted) and Fall (N = 9686, unweighted) 2020, and Winter 2021 (N = 11,107, unweighted). Binary logistic regression was used to model for adjusted odds of self-reports of being unable to access different types of care. RESULTS: In three time periods from March 2020 through March/April 2021 beneficiaries with diabetes plus MCC combinations reported being unable to get medical care, compared to beneficiaries with diabetes alone. Notably, patterns persisted at the 12-month mark with beneficiaries with diabetes plus cancer (OR = 1.24), and diabetes plus cancer/stroke (OR = 2.53) experiencing increased odds of being unable to get care because of COVID-19, compared to beneficiaries with diabetes alone. By March/April 2021 beneficiaries with diabetes plus COPD (OR = 1.08), diabetes plus stroke (OR = 1.49), and diabetes plus Alzheimer's (OR = 1.09) experienced increased odds of being unable to get treatment for ongoing conditions. Beneficiaries with diabetes plus Alzheimer's (OR = 1.40) also experienced increased odds of being unable to get a regular check-up 12 months into the pandemic. Finally, members of racial/ethnic minority groups experienced increased odds of being unable to obtain services at various times during the pandemic compared to non-Hispanic Whites, with increased odds persisting at 12 months for non-Hispanic Blacks and Hispanics. CONCLUSIONS: Beneficiaries with MCC, and minorities, experienced increased odds of being unable to obtain some services during COVID-19, even when controlling for similar diabetes and MCC combinations. Work remains for providers and public health systems to dismantle and reimagine systems to provide equitable access to care.
Subject(s)
Alzheimer Disease , COVID-19 , Diabetes Mellitus , Multiple Chronic Conditions , Stroke , Aged , United States/epidemiology , Humans , Ethnicity , Medicare , COVID-19/epidemiology , Pandemics , Retrospective Studies , Minority Groups , Diabetes Mellitus/epidemiology , Diabetes Mellitus/therapy , Health Services AccessibilityABSTRACT
Background: Many people with chronic conditions do not have a single condition: 4.9 million (20%) Australians had multimorbidity (2 or more chronic conditions) in 2017-18. Understanding which conditions co-occur can inform treatment guidelines. Aim/Objectives: This study performed analysis on Australian Bureau of Statistics 2017-18 National Health Survey (NHS) data to identify conditions that commonly co-occur, and that co-occur at a higher than expected prevalence. Due to limitations of the 2020-21 NHS, the 2017-18 NHS remains the most recent, robust source of self-report chronic condition information for national reporting. This work provides baseline information on chronic condition multimorbidity in Australia, before the COVID-19 pandemic. Method(s): Analysis was restricted to people aged 45 and over (most people with multimorbidity). Using 10 selected chronic conditions, weighted age-adjusted estimates of observed and expected events for each combination of two conditions were calculated. To identify pairs of conditions that co-occurred at a higher than expected prevalence, the ratio of observed to expected prevalence was assessed using a 95% confidence interval. Finding(s): Over half of the condition pairs tested were significantly associated. The most strongly associated conditions were asthma with COPD (with co-occurrence 3.5 times as high as expected), diabetes with chronic kidney disease (2.5 times as high), and cardiovascular diseases with chronic kidney disease (2.3 times as high). Implications: Multimorbidity is common, with many conditions co-occurring more frequently than expected by chance. There were strong associations between asthma and COPD, diabetes and chronic kidney disease, and cardiovascular diseases and chronic kidney disease. Developing treatment guidelines that consider common multimorbidities would support holistic patient care.