Abstract Comorbidity is associated with worse health outcomes, more complex clinical management, and increased health care costs. There is no agreement, however, on the meaning of the term, and ...related constructs, such as multimorbidity, morbidity burden, and patient complexity, are not well conceptualized. In this article, we review definitions of comorbidity and their relationship to related constructs. We show that the value of a given construct lies in its ability to explain a particular phenomenon of interest within the domains of (1) clinical care, (2) epidemiology, or (3) health services planning and financing. Mechanisms that may underlie the coexistence of 2 or more conditions in a patient (direct causation, associated risk factors, heterogeneity, independence) are examined, and the implications for clinical care considered. We conclude that the more precise use of constructs, as proposed in this article, would lead to improved research into the phenomenon of ill health in clinical care, epidemiology, and health services.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
Clinical Care and Health Disparities STARFIELD, B; GERVAS, J; MANGIN, D
Annual review of public health,
04/2012, Volume:
33, Issue:
1
Journal Article
Peer reviewed
Open access
Health disparities, also known as health inequities, are systematic and potentially remediable differences in one or more aspects of health across population groups defined socially, economically, ...demographically, or geographically. This topic has been the subject of research stretching back at least decades. Reports and studies have delved into how inequities develop in different societies and, with particular regard to health services, in access to and financing of health systems. In this review, we consider empirical studies from the United States and elsewhere, and we focus on how one aspect of health systems, clinical care, contributes to maintaining systematic differences in health across population groups characterized by social disadvantage. We consider inequities in clinical care and the policies that influence them. We develop a framework for considering the structural and behavioral components of clinical care and review the existing literature for evidence that is likely to be generalizable across health systems over time. Starting with the assumption that health services, as one aspect of social services, ought to enhance equity in health care, we conclude with a discussion of threats to that role and what might be done about them.
Over time, the definition of prevention has expanded so that its meaning in the context of health services is now unclear. As risk factors are increasingly considered to be the equivalent of ...“diseases” for purposes of intervention, the concept of prevention has lost all practical meaning. This paper reviews the inconsistencies in its utility, and suggests principles that it should follow in the future: a population orientation with explicit consideration of attributable risk, the setting of priorities based on reduction in illness and avoidance of adverse effects, and the imperative to reduce inequities in health.
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BFBNIB, CMK, NMLJ, NUK, PNG, SAZU, UL, UM, UPUK
The distinction between a chronic illness and a non-chronic illness is generally made according to the likelihood of its lasting for 12 months or more and resulting in functional limitations and/or ...need for ongoing medical care. 1 Data from population-based studies of visits to medical facilities show that people with a "diagnosed" chronic illness often do not have that diagnosis from year to year, and people who have one or more of a large number of non-chronic illnesses that are widely believed to be short-term often have recurring episodes of the same or related illnesses over the long term. Primary care Primary care: primary care is that aspect of a health services system that assures person focused care over time to a defined population, accessibility to facilitate receipt of care when it is first needed, comprehensiveness of care in the sense that only rare or unusual manifestations of ill health are referred elsewhere, and coordination of care such that all facets of care (wherever received) are integrated.
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BFBNIB, CMK, NMLJ, NUK, PNG, SAZU, UL, UM, UPUK
The impact of comorbidity on use of primary care and specialty services is poorly understood. The purpose of this study was to determine the relationship between morbidity burden, comorbid ...conditions, and use of primary care and specialist services
The study population was a 5% random sample of Medicare beneficiaries, taken from 1999 Medicare files. We analyzed the number of ambulatory face-to-face patient visits to primary care physicians and specialists for each diagnosis, with each one first considered as the "main" one and then as a comorbid diagnosis to another. Each patient was categorized by extent of total morbidity burden using the Johns Hopkins Adjusted Clinical Group case-mix system.
Higher morbidity burden was associated with more visits to specialists, but not to primary care physicians. Patients with most diagnoses had more visits, both to primary care and specialist physicians for comorbid diagnoses than for the main diagnosis itself. Although patients, especially those with high morbidity burdens, generally made more visits to specialists than to primary care physicians, this finding was not always the case. For patients with 66 diagnoses, primary care visits for those diagnoses exceeded specialist visits in all morbidity burden groups; for patients with 87 diagnoses, specialty visits exceeded primary care visits in all morbidity burden groups.
In the elderly, a high morbidity burden leads to higher use of specialist physicians, but not primary care physicians, even for patients with common diagnoses not generally considered to require specialist care. This finding calls for a better understanding of the relative roles of generalists and specialists in the US health services system.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
Although comorbidity is very common in the population, little is known about the types of health service that are used by people with comorbid conditions.
Data from claims on the nonelderly were ...classified by diagnosis and extent of comorbidity, using a case-mix measure known as the Johns Hopkins Adjusted Clinical Groups, to study variation in extent of comorbidity and resource utilization. Visits of patients (adults and children) with 11 conditions were classified as to whether they were to primary care physicians or to other specialists, and whether they involved the chosen condition or other conditions.
Comorbidity varied within each diagnosis; resource use depended on the degree of comorbidity rather than the diagnosis. When stratified by degree of comorbidity, the number of visits for comorbid conditions exceeded the number of visits for the index condition in almost all comorbidity groups and for visits to both primary care physicians and to specialists. The number of visits to primary care physicians for both the index condition and for comorbid conditions almost invariably exceeded the number of visits to specialists. These patterns differed only for uncommon conditions in which specialists played a greater role in the care of the condition, but not for comorbid conditions.
In view of the high degree of comorbidity, even in a nonelderly population, single-disease management does not appear promising as a strategy to care for patients. In contrast, the burden is on primary care physicians to provide the majority of care, not only for the target condition but for other conditions. Thus, management in the context of ongoing primary care and oriented more toward patients' overall health care needs appears to be a more promising strategy than care oriented to individual diseases. New paradigms of care that acknowledge actual patterns of comorbidities as well as the need for close coordination between generalists and specialists require support.
This study assessed whether income inequality and primary care physician supply have a different effect on mortality among Blacks compared with Whites.
We conducted a multivariate ecologic analysis ...of 1990 data from 273 US metropolitan areas.
Both income inequality and primary care physician supply were significantly associated with White mortality (P < .01). After the inclusion of the socioeconomic status covariates, the effect of income inequality on Black mortality remained significant (P < .01), but the effect of primary care physician supply was no longer significant (P > .10), particularly in areas with high income inequality.
Improvement in population health requires addressing socioeconomic determinants of health, including income inequality and primary care availability and access.
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CEKLJ, DOBA, FSPLJ, IZUM, KILJ, NUK, ODKLJ, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK, VSZLJ
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