Multimorbidity: can general practitioners identify the health conditions most important to their patients? Results from a national cross-sectional study in Switzerland.

BACKGROUND: Faced with patients suffering from more than one chronic condition, or multimorbidity, general practitioners (GPs) must establish diagnostic and treatment priorities. Patients also set their own priorities to handle the everyday burdens associated with their multimorbidity and these may be different from the priorities established by their GP. A shared patient-GP agenda, driven by knowledge of each other's priorities, would seem central to managing patients with multimorbidity. We evaluated GPs' ability to identify the health condition most important to their patients. METHODS: Data on 888 patients were collected as part of a cross-sectional Swiss study on multimorbidity in family medicine. For the main analyses on patients-GP agreement, data from 572 of these patients could be included. GPs were asked to identify the two conditions which their patient considered most important, and we tested whether either of them agreed with the condition mentioned as most important by the patient. In the main analysis, we studied the agreement rate between GPs and patients by grouping items medically-related into 46 groups of conditions. Socio-demographic and clinical variables were fitted into univariate and multivariate models. RESULTS: In 54.9% of cases, GPs were able to identify the health condition most important to the patient. In the multivariate model, the only variable significantly associated with patient-GP agreement was the number of chronic conditions: the higher the number of conditions, the less likely the agreement. CONCLUSION: GPs were able to correctly identify the health condition most important to their patients in half of the cases. It therefore seems important that GPs learn how to better adapt treatment targets and priorities by taking patients' perspectives into account.

Prevalence of multimorbidity in general practice: a cross-sectional study within the Swiss Sentinel Surveillance System (Sentinella).

OBJECTIVES: To estimate the prevalence of multimorbidity using a list of 75 chronic conditions derived from the International Classification for Primary Care, Second edition and developed specifically to assess multimorbidity in primary care. Our aim was also to provide prevalence data for multimorbidity in primary care in a country in which general practitioners (GPs) do not play a gatekeeping role in the health system. SETTING: A representative sample of GPs within the Swiss Sentinel Surveillance Network. PARTICIPANTS: 118 GPs completed a paper-based questionnaire about 25 consecutive patients of all ages between September and November 2015. There were no patient exclusion criteria. Recorded data included date of birth, gender and the patients' chronic conditions. PRIMARY AND SECONDARY OUTCOME MEASURES: We estimated the prevalence of multimorbidity, defined as ≥2, and ≥3 chronic conditions stratified by gender and age group, and adjusted for clustering by GPs. We also computed the prevalence of each chronic condition individually and grouped by system. RESULTS: Data from 2904 patients were included (mean age (SD)=56.5 (20.5) years; male=43.7%). Prevalence was 52.1% (95% CI 48.6% to 55.5%) for ≥2 and 35.0% (95% CI 31.6% to 38.5%) for ≥3 chronic conditions, with no significant gender differences. Prevalence of two or more chronic conditions was low (6.2%, 95% CI 2.8% to 13.0%) in those below 20 but affected more than 85% (85.8%, 95% CI 79.6% to 90.3%) of those above the age of 80. The most prevalent conditions were cardiovascular (42.7%, 95% CI 39.7% to 45.7%), psychological (28.5%, 95% CI 26.1% to 31.1%) and metabolic or endocrine disorders (24.1%, 95% CI 21.6% to 26.7%). Elevated blood pressure was the most prevalent cardiovascular condition and depression the most common psychological disorder. CONCLUSION: In a country in which GPs do not play a gatekeeping role within the health system, the prevalence of multimorbidity, as assessed using a list of chronic conditions specifically relevant to primary care, is high and increases with age.

Factors associated with health literacy in multimorbid patients in primary care: a cross-sectional study in Switzerland.

OBJECTIVE: To identify factors associated with health literacy in multimorbid patients. DESIGN: A nationwide cross-sectional study in Switzerland. Univariate and multivariate linear regressions were calculated to identify variables associated with health literacy. A multiple imputation approach was used to deal with missing values. PARTICIPANTS: Multimorbid patients recruited in primary care settings (n=888), above 18 years old and suffering from at least 3 of 75 chronic conditions on a predefined list based on the International Classification of Primary Care 2. MAIN MEASURES: Health literacy was assessed using the European Health Literacy Survey project questionnaire (HLS-EU 6). This comprises six items scored from 1 to 4 (very difficult=1, fairly difficult=2, fairly easy=3, very easy=4), and the total health literacy score is computed as their mean. As we wished to understand the determinants associated with lower health literacy, the HLS-EU 6 score was the only dependent variable; all other covariates were considered independent. RESULTS: The mean health literacy score (SD) was 2.9 (0.5). Multivariate analyses found significant associations between low health literacy scores and treatment burden scores (ß=-0.004, 95% CI -0.006 to 0.002); marital status, predominantly the divorced group (ß=0.136, 95% CI 0.012 to 0.260); dimensions of the EuroQuol 5 Dimension 3 Level (EQ5D3L) quality of life assessment, that is, for moderate problems with mobility (ß=-0.086, 95% CI -0.157 to 0.016); and with moderate problems (ß=-0.129, 95% CI -0.198 to 0.060) and severe problems with anxiety/depression (ß=-0.343, 95% CI -0.500 to 0.186). CONCLUSIONS: Multimorbid patients with a high treatment burden, altered quality of life by problems with mobility, anxiety or depression, often also have low levels of health literacy. Primary care practitioners should therefore pay particular attention to these patients in their daily practice.

Comparing the self-perceived quality of life of multimorbid patients and the general population using the EQ-5D-3L.

OBJECTIVES: To assess and compare the self-perceived Health Related Quality of Life (HRQoL) of multimorbid patients and the general population using health utilities (HU) and visual analogue scale (VAS) methods. METHODS: We analyzed data (n = 888) from a national, cross-sectional Swiss study of multimorbid patients recruited in primary care settings. Self-perceived HRQoL was assessed using the EQ-5D-3L instrument, composed of 1) a questionnaire on the five dimensions of mobility, self-care, usual activities, pain/discomfort, and anxiety/depression (EQ-5D dimensions), and 2) a 0-100 (0 = worst- and 100 = best-imaginable health status) VAS. We described the EQ-5D dimensions and VAS and computed HU using a standard pan-European value set. HU and VAS are the two components of the overall HRQoL assessment. We examined the proportions of multimorbid patients reporting problems (moderate/severe) in each EQ-5D dimension, corresponding proportions without problems, and mean HU and VAS values across patient characteristics. To test differences between subgroups, we used chi-square tests for dichotomous outcomes and T-tests (ANOVA if more than two groups) for continuous outcomes. Finally, we compared observed and predicted HU and VAS values. RESULTS: All 888 participants answered every EQ-5D item. Mean (SD) HU and VAS values were 0.70 (0.18) and 63.2 (19.2), respectively. HU and VAS were considerably and significantly lower in multimorbid patients than in the general population and were also lower in multimorbid patients below 60 years old and in women. Differences between observed and predicted means (SD) were -0.07 (0.18) for HU and -11.8 (20.3) for VAS. CONCLUSIONS: Self-perceived HRQoL is considerably and significantly affected by multimorbidity. More attention should be given to developing interventions that improve the HRQoL of multimorbid patients, particularly women and those aged below 60 years old.

From chronic conditions to relevance in multimorbidity: a four-step study in family medicine.

BACKGROUND: Chronic conditions and multimorbidity (MM) are major concerns in family medicine (FM). OBJECTIVES: Based on the International Classification of Primary Care, Second Edition (ICPC-2), this study aimed to list (i)the chronic conditions and (ii)those most relevant to MM in FM. METHODS: A panel of FM experts used a four-step process to identify chronic conditions among ICPC-2 items and list chronic conditions most relevant in MM. They also evaluated the importance of eight criteria, previously identified in the literature, for characterizing chronic conditions. Step one involved a focus group of five experts. Steps two, three and four involved 10, 25 and 25 experts, respectively. They rated ICPC-2 items via an online questionnaire using a Likert scale from 1 (never chronic/irrelevant in MM) to 9 (always chronic/always relevant in MM). A median value cut-off was used to evaluate appropriateness of each item and the inter-percentile range adjusted for symmetry to determine the agreement/disagreement between experts. In parallel, in steps two and three, experts rated the importance of eight criteria to characterize chronic conditions, using a Likert scale from 1 (strongly disagree) to 9 (strongly agree). RESULTS: Of the ICPC-2's 686 items, experts identified 139 chronic conditions, of which 75 were deemed most relevant in the context of MM. Four of the eight criteria were retained as important to define chronic conditions: duration, sequelae, recurrence/pattern and the diagnosis itself. CONCLUSION: Using this list of 75 chronic conditions most relevant in the context of MM should enhance the validity of studies of MM in FM.

Bidirectional relationship between the body mass index and substance use in young men.

BACKGROUND: Obesity and substance use are major concern in young people. This study explored the bidirectional longitudinal relationships between the body mass index (BMI) of young men and their use of (1) 4 classes of nonmedical prescription drugs; (2) alcohol; (3) tobacco; and (4) cannabis. METHODS: Baseline and follow-up data from the Cohort Study on Substance Use Risk Factors were used (N = 5007). A cross-lagged panel model, complemented by probit models as sensitivity analysis, was run to determine the bidirectional relationships between BMI and substance use. Alcohol was assessed using risky single-occasion drinking (RSOD); tobacco, using daily smoking; and cannabis, using hazardous cannabis use (defined as twice-weekly or more cannabis use). Nonmedical prescription drugs use (NMPDU) included opioid analgesics, sedatives/sleeping pills, anxiolytics, and stimulants. RESULTS: Different associations were found between BMI and substance use. Only RSOD (ß = -.053, P = .005) and NMPDU of anxiolytics (ß = .040, P = .020) at baseline significantly predicted BMI at follow-up. Baseline RSOD predicted a lower BMI at follow-up, whereas baseline NMPDU of anxiolytics predicted higher BMI at follow-up. Furthermore, BMI at baseline significantly predicted daily smoking (ß = .050, P = .007) and hazardous cannabis use (ß = .058, P = .030). CONCLUSIONS: These results suggest different associations between BMI and the use of various substances by young men. However, only RSOD and NMPDU of anxiolytics predicted BMI, whereas BMI predicted daily smoking and hazardous cannabis use.

Video Gaming Disorder and Sport and Exercise in Emerging Adulthood: A Longitudinal Study.

Among the negative consequences of video gaming disorder, decreased participation in sport and exercise has received little attention. This study aimed to assess the longitudinal association between video gaming disorder and the level of sport and exercise in emerging adult men. A questionnaire was completed at baseline and 15-month follow-up by a representative national sample of 4,933 respondents. The seven items of the Game Addiction Scale were used to construct a latent variable representing video gaming disorder. Level of sport and exercise was also self-reported. Cross-lagged path modeling indicated a reciprocal causality between video gaming disorder and the level of sport and exercise, even after adjusting for a large set of confounders. These findings support the need for better promotion of sport and exercise among emerging adults in order to contribute to the prevention of video gaming disorder, and to raise the level of sport and exercise activity in addicted gamers.

Drinking locations and alcohol-related harm: Cross-sectional and longitudinal associations in a sample of young Swiss men.

BACKGROUND: Alcohol consumption--in particular drinking volume (DV) and risky single occasion drinking (RSOD)--has been related to a wide range of negative consequences and health problems. Previous studies also suggested that drinking in certain locations may be more strongly associated with the occurrence of alcohol-related harm than drinking in others. However, they were conducted in countries culturally and legally different from European countries and were limited to cross-sectional designs. This study investigates the cross-sectional and longitudinal associations of alcohol-related harm with DVs in different locations in a sample of young Swiss men. METHODS: A representative sample of 4536 young Swiss male drinkers completed baseline and 15-month follow-up questionnaires. These assessed DVs in 11 locations, alcohol-related harm (i.e. number of alcohol-related consequences and alcohol use disorder criteria) and frequency of RSOD. Cross-sectional and longitudinal associations of alcohol-related harm with DVs in each location were tested using regression models, with and without adjustment for frequency of RSOD. RESULTS: Both cross-sectional and longitudinal analyses showed significant positive associations between alcohol-related harm and DVs at friends' homes, in discos/nightclubs and in outdoor public places, when controlling for frequency of RSOD. In contrast, the contribution of DVs at one's own home and in restaurants was consistently not significant when adjusted for frequency of RSOD. When controlling for RSOD, associations between alcohol-related harm and DVs in bars/pubs, when playing sports, during other leisure activities, at cinemas/theatres, during sporting events, and during special events were not consistent between cross-sectional and longitudinal analyses. CONCLUSION: Results suggest that prevention interventions should not only target reducing the overall volume of alcohol consumed and the frequency of RSOD in general, but they should additionally focus on limiting alcohol consumption in outdoor public places, discos/nightclubs, and in friends' homes in particular, or at least on preventing harm occurring in these occasions.

Association between non-medical prescription drug use and personality traits among young Swiss men.

AIM: To investigate the relationships between six classes of non-medical prescription drug use (NMPDU) and five personality traits. METHODS: Representative baseline data on 5777 Swiss men around 20 years old were taken from the Cohort Study on Substance Use Risk Factors. NMPDU of opioid analgesics, sedatives/sleeping pills, anxiolytics, antidepressants, beta-blockers and stimulants over the previous 12 months was measured. Personality was assessed using the Brief Sensation Seeking Scale; attention deficit-hyperactivity (ADH) using the Adult Attention-Deficit-Hyperactivity Disorder Self-Report Scale; and aggression/hostility, anxiety/neuroticism and sociability using the Zuckerman-Kuhlmann Personality Questionnaire. Logistic regression models for each personality trait were fitted, as were seven multiple logistic regression models predicting each NMPDU adjusting for all personality traits and covariates. RESULTS: Around 10.7% of participants reported NMPDU in the last 12 months, with opioid analgesics most prevalent (6.7%), then sedatives/sleeping pills (3.0%), anxiolytics (2.7%), and stimulants (1.9%). Sensation seeking (SS), ADH, aggression/hostility, and anxiety/neuroticism (but not sociability) were significantly positively associated with at least one drug class (OR varied between 1.24, 95%CI: 1.04-1.48 and 1.86, 95%CI: 1.47-2.35). Aggression/hostility, anxiety/neuroticism and ADH were significantly and positively related to almost all NMPDU. Sociability was inversely related to NMPDU of sedatives/sleeping pills and anxiolytics (OR, 0.70; 95%CI: 0.51-0.96 and OR, 0.64; 95%CI: 0.46-0.90, respectively). SS was related only to stimulant use (OR, 1.74; 95%CI: 1.14-2.65). CONCLUSION: People with higher scores for ADH, aggression/hostility and anxiety/neuroticism are at higher risk of NMPDU. Sociability appeared to protect from NMPDU of sedatives/sleeping pills and anxiolytics.

Association between nonmedical prescription drug use and health status among young Swiss men.

PURPOSE: To examine the relationship between the nonmedical prescription drug use (NMPDU) of six drug classes and health. METHODS: Data on young adults males (mean age, 19.96 years) from the baseline and follow-up of the Cohort Study on Substance Use Risk Factors (C-SURF) were used (n = 4,958). Two sets of logistic regression models were fitted to examine the associations between NMPDU of opioid analgesics, sedatives or sleeping pills, anxiolytics, antidepressants, beta blockers and stimulants, and health status (assessed using the Medical Outcomes Study 12-Item Short Form Survey Instrument [SF-12 v2]). We first computed odds ratios between NMPDU at baseline and poor mental and physical health at follow-up, adjusting for poor mental or physical health at baseline. We then computed odds ratios between poor mental and physical health at baseline and NMPDU at follow-up, adjusting for NMPDU at baseline. RESULTS: Three key findings regarding mental health were (1) there was a reciprocal risk between poor mental health and sedatives and anxiolytics; (2) poor mental health increased NMPDU of opioid analgesics and antidepressants but not vice versa; and (3) there were no associations with stimulants. Three key findings regarding physical health were (1) poor physical health increased the risk of NMPDU of anxiolytics; (2) the only reciprocal risk was between physical health and NMPDU of opioid analgesics; and (3) there were no associations with stimulants. CONCLUSION: These results, among the first ever on reciprocal effects between NMPDU and mental and physical health status, give unique information concerning the adverse effects of NMPDU on health and vice versa. The study shows that NMPDU is not only a sign of self-medication but may induce health problems.

Health impact of sport and exercise in emerging adult men: a prospective study.

PURPOSE: Health benefits of sport and exercise are well documented in children, adolescents and adults, but little is known about emerging adulthood-a period of life characterized by significant demographic and developmental changes. The present study aimed to assess the health impact of changes in sport and exercise levels during that specific period of life. METHODS: The analysis used baseline and 15-month follow-up data (N = 4,846) from the cohort study on substance use risk factors. Associations between baseline exercise levels or changes in exercise levels and health indicators (i.e., health-related quality of life, depression, body mass index, alcohol dependence, nicotine dependence and cannabis use disorder) were measured using chi-squared tests and ANOVA. Direction of effects was tested using cross-lagged analysis. RESULTS: At baseline, all health indicator scores were observed to be better for regular exercisers than for other exercise levels. At follow-up, participants who had maintained regular exercise over time had better scores than those who had remained irregular exercisers or had discontinued, but their scores for health-related quality of life and depression were close to those of participants who had adopted regular exercise after the baseline questionnaire. Cross-lagged analysis indicated that regular exercise at baseline was a significant predictor of health-related quality of life and substance use dependence at follow-up, but was itself predicted only by health-related quality of life. CONCLUSIONS: From a health promotion perspective, this study emphasizes how important it is for emerging adult men to maintain, or adopt, regular sport and exercise.

Use of neuroenhancement drugs: prevalence, frequency and use expectations in Switzerland.

OBJECTIVE: The present study investigates the use expectations, prevalence and frequency of neuroenhancement drug (ND) use among the Swiss male population, separating college students from others. METHODS: Young Swiss men were invited to participate in the Cohort Study on Substance Use Risk Factors. A total of 5,967 participants responded to questions on six types of NDs (wakefulness medication, antidepressants, Alzheimer's disease medication, Parkinson's disease medication, attention deficit-hyperactivity disorder (ADHD) medication, and beta-blockers). The frequency of use depending on five expectations (to enhance wakefulness, attention, memory, concentration and stress reduction) was analyzed for a twelve-month period. RESULTS: (1) About 3% of the sample indicated use of at least one ND; (2) ADHD medication was the most prevalent; (3) The type of ND preferred differed depending on academic status (4). Quantitatively, over the year, college student users used ND much less frequently than other users. CONCLUSIONS: Prevalence of ND use is low in Switzerland relative to other countries such as the United States. Patterns of ND use differed depending on academic status, suggesting that while college student ND users tended to do so rarely (probably to enhance cognitive abilities for exams), non-college male users used other NDs more frequently (probably to "get high").

Peer pressure and alcohol use in young men: a mediation analysis of drinking motives.

BACKGROUND: Peer pressure (PP) has been shown to play a major role in the development and continuation of alcohol use and misuse. To date, almost all the studies investigating the association of PP with alcohol use only considered the PP for misconduct but largely ignored other aspects of PP, such as pressure for peer involvement and peer conformity. Moreover, it is not clear whether the association of PP with alcohol use is direct or mediated by other factors. The aim of the present study was to investigate the association of different aspects of peer pressure (PP) with drinking volume (DV) and risky single-occasion drinking (RSOD), and to explore whether these associations were mediated by drinking motives (DM). METHODS: A representative sample of 5521 young Swiss men, aged around 20 years old, completed a questionnaire assessing their usual weekly DV, the frequency of RSOD, DM (i.e. enhancement, social, coping, and conformity motives), and 3 aspects of PP (i.e. misconduct, peer involvement, and peer conformity). Associations between PP and alcohol outcomes (DV and RSOD) as well as the mediation of DM were tested using structural equation models. RESULTS: Peer pressure to misconduct was associated with more alcohol use, whereas peer involvement and peer conformity were associated with less alcohol use. Associations of drinking outcomes with PP to misconduct and peer involvement were partially mediated by enhancement and coping motives, while the association with peer conformity was partially mediated by enhancement and conformity motives. CONCLUSIONS: Results suggest that PP to misconduct constitutes a risk factor, while peer conformity and peer involvement reflect protective factors with regard to alcohol use. Moreover, results from the mediation analyses suggest that part of the association of PP with alcohol use came indirectly through DM: PP was associated with DM, which in turn were associated with alcohol use.

Patterns of cannabis use and prospective associations with health issues among young males.

BACKGROUND AND AIMS: To test prospective associations between cannabis disorder symptoms/frequency of cannabis use and health issues and to investigate stability versus transience in cannabis use trajectories. DESIGN: Two waves of data collection from the longitudinal Cohort Study on Substance Use Risk Factors (C-SURF). SETTING: A representative sample of young Swiss men in their early 20s from the general population. PARTICIPANTS: A total of 5084 young men (mean age 19.98 ± 1.19 years at time 1). MEASUREMENTS: Cannabis use (life-time use, frequency of use, cannabis disorder symptoms) and self-reported measures of health issues (depression, mental/physical health, health consequences) were assessed. Significant changes in cannabis use were tested using t-test/Wilcoxon's rank test for paired data. Cross-lagged panel models provided evidence regarding longitudinal associations between cannabis use and health issues. FINDINGS: Most of the participants (84.5%) remained in the same use category and cannabis use kept to similar levels at times 1 and 2 (P = 0.114 and P = 0.755; average of 15 ± 2.8 months between times 1 and 2). Cross-lagged panel models showed that cannabis disorder symptoms predicted later health issues (e.g. depression, ß = 0.087, P < 0.001; health consequences, ß = 0.045, P < 0.05). The reverse paths from health issues to cannabis disorder symptoms and the cross-lagged panel model between frequency of cannabis use and health issues were non-significant. CONCLUSIONS: Patterns of cannabis use showed substantial continuity among young Swiss men in their early 20s. The number of symptoms of cannabis use disorder, rather than the frequency of cannabis use, is a clinically important measure of cannabis use among young Swiss men.

Community-based measles mortality surveillance in two districts of Katanga Province, Democratic Republic of Congo.

BACKGROUND: Mortality due to measles is often under-reported. Traditional methods of measuring mortality can be time and resource-intensive. We describe the implementation of a community-based method to monitor measles mortality. FINDINGS: Using standardized questionnaires in the midst of a measles outbreak, a community-based network of volunteers recorded a much larger number of deaths (376) than deaths recorded in health centres (27). Deaths were predominantly (93.5%) among children aged less than 5 years; 54.5% of measles deaths reported antecedent measles vaccination. CONCLUSIONS: In this setting, the number of deaths due to measles reported in community-based surveillance was much higher than deaths reported in health centres. Lack of reliable population data and incomplete coverage of the surveillance system make it impossible to calculate overall attack rates and cause-specific mortality rates. Similar systems could be rapidly implemented in other difficult outbreak settings.