IMPORTANCE: Documentation rates of patients’ medical wishes are often low. It is unknown whether easy-to-use, patient-facing advance care planning (ACP) interventions can overcome barriers to ...planning in busy primary care settings. OBJECTIVE: To compare the efficacy of an interactive, patient-centered ACP website (PREPARE) with an easy-to-read advance directive (AD) to increase planning documentation. DESIGN, SETTING, AND PARTICIPANTS: This was a comparative effectiveness randomized clinical trial from April 2013 to July 2016 conducted at multiple primary care clinics at the San Francisco VA Medical Center. Inclusion criteria were age of a least 60 years; at least 2 chronic and/or serious conditions; and 2 or more primary care visits; and 2 or more additional clinic, hospital, or emergency room visits in the last year. INTERVENTIONS: Participants were randomized to review PREPARE plus an easy-to-read AD or the AD alone. There were no clinician and/or system-level interventions or education. Research staff were blinded for all follow-up measurements. MAIN OUTCOMES AND MEASURES: The primary outcome was new ACP documentation (ie, legal forms and/or discussions) at 9 months. Secondary outcomes included patient-reported ACP engagement at 1 week, 3 months, and 6 months using validated surveys of behavior change process measures (ie, 5-point knowledge, self-efficacy, readiness scales) and action measures (eg, surrogate designation, using a 0-25 scale). We used intention-to-treat, mixed-effects logistic and linear regression, controlling for time, health literacy, race/ethnicity, baseline ACP, and clustering by physician. RESULTS: The mean (SD) age of 414 participants was 71 (8) years, 38 (9%) were women, 83 (20%) had limited literacy, and 179 (43%) were nonwhite. No participant characteristic differed significantly among study arms at baseline. Retention at 6 months was 90%. Advance care planning documentation 6 months after enrollment was higher in the PREPARE arm vs the AD-alone arm (adjusted 35% vs 25%; odds ratio, 1.61 95% CI, 1.03-2.51; P = .04). PREPARE also resulted in higher self-reported ACP engagement at each follow-up, including higher process and action scores; P <.001 at each follow-up). CONCLUSIONS AND RELEVANCE: Easy-to-use, patient-facing ACP tools, without clinician- and/or system-level interventions, can increase planning documentation 25% to 35%. Combining the PREPARE website with an easy-to-read AD resulted in higher planning documentation than the AD alone, suggesting that PREPARE may increase planning documentation with minimal health care system resources. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01550731
Abstract
Up to 85% of adult cancer survivors and 99% of adult survivors of childhood cancer live with an accumulation of chronic conditions, frailty, and/or cognitive impairments resulting from ...cancer and its treatment. Thus, survivors often show an accelerated development of multiple geriatric syndromes and need therapeutic interventions. To advance progress in this area, the National Cancer Institute convened the second of 2 think tanks under the auspices of the Cancer and Accelerated Aging: Advancing Research for Healthy Survivors initiative. Experts assembled to share evidence of promising strategies to prevent, slow, or reverse the aging consequences of cancer and its treatment. The meeting identified research and resource needs, including geroscience-guided clinical trials; comprehensive assessments of functional, cognitive, and psychosocial vulnerabilities to assess and predict age-related outcomes; preclinical and clinical research to determine the optimal dosing for behavioral (eg, diet, exercise) and pharmacologic (eg, senolytic) therapies; health-care delivery research to evaluate the efficacy of integrated cancer care delivery models; optimization of intervention implementation, delivery, and uptake; and patient and provider education on cancer and treatment-related late and long-term adverse effects. Addressing these needs will expand knowledge of aging-related consequences of cancer and cancer treatment and inform strategies to promote healthy aging of cancer survivors.
Background
Having more than one chronic condition is common and is associated with greater health care utilization, higher medication burden and complexity of treatment. However, clinical practice ...guidelines (CPGs) do not routinely address the balance between harms and benefits of treatments for people with multiple chronic conditions (MCCs).
Objective
To partner with the Kaiser Permanente Integrated Cardiovascular Health (ICVH) program to engage multiple stakeholders in a mixed-methods approach in order to: 1) identify two high-priority clinical questions related to MCCs, and 2) understand patients’ and family caregivers’ perceptions of meaningful outcomes to inform benefit/harm assessments for these two high-priority questions. These clinical questions and outcomes will be used to inform CPG recommendations for people with MCCs.
Design and Participants
The ICVH program provided 130 topics rank-ordered by the potential for finding evidence that would change clinical recommendations regarding the topic. We used a modified Delphi method to identify and reword topics into questions relevant to people with MCCs. We used two sets of focus groups (
n
= 27) to elicit patient and caregiver perspectives on two important research questions and relevant patient-important outcomes on benefit/harm balance for people with MCCs.
Key Results
Co-investigators, patients and caregivers identified “optimal blood pressure goals” and “diabetes medication management” as important clinical topics for CPGs related to people with MCCs. Stakeholders identified a list of relevant outcomes to be addressed in future CPG development including 1) physical function and energy, 2) emotional health and well-being, 3) avoidance of treatment burden, side effects and risks, 4) interaction with providers and health care system, and 5) prevention of adverse long-term health outcomes.
Conclusions
Through the application of a mixed-methods process, we identified the questions regarding optimal blood pressure goals and diabetes medication management, along with related patient-centered outcomes, to inform novel evidence syntheses for those with MCCs. This study provides the lessons learned and a generalizable process for CPG developers to engage patient and caregivers in priority-setting for the translation of evidence into future CPGs. Ultimately, engaging patient and stakeholders around MCCs could improve the relevance of CPGs for the care of people with MCCs.
The U.S. Department of Health and Human Services recently called for a paradigm shift from the study of individual chronic conditions to multiple chronic conditions (MCCs). We identify the most ...common combinations of chronic diseases experienced by a sample of community-dwelling older people and assess whether depression is differentially associated with combinations of illnesses.
Self-reports of diagnosed chronic conditions and depressive symptoms were provided by 5,688 people participating in the ORANJ BOWL(SM) research panel. Each respondent was categorized as belonging to one of 32 groups. ANOVA examined the association between depressive symptoms and combinations of illnesses.
People with more health conditions experienced higher levels of depression than people with fewer health conditions. People with some illness combinations had higher levels of depressive symptoms than people with other illness combinations.
Findings confirm extensive variability in the combinations of illnesses experienced by older adults and demonstrate the complex associations of specific illness combinations with depressive symptoms. Results highlight the need to expand our conceptualization of research and treatment around MCCs and call for a person-centered approach that addresses the unique needs of individuals with MCCs.
OBJECTIVEInflammatory bowel disease (IBD) was shown to be associated with a variety of chronic comorbidities. We aimed to evaluate the frequency of 21 chronic conditions and compared frequencies in ...IBD and non-IBD populations. Further, healthcare costs of those (additional) chronic conditions were calculated.
PATIENTS AND METHODSA total of 4791 IBD patients, who were insured at Helsana Insurance Group in 2014, were compared with 1 114 638 individuals without IBD. Entropy balancing was performed to create balanced samples. Chronic conditions were identified by means of the updated Pharmacy-based Cost Group model. Multivariate log-transformed linear regression modeling was performed to estimate the effect of the morbidity status (non-IBD +none, +1, +2, and +3 or more chronic conditions) on the healthcare costs.
RESULTSOverall, 78% of IBD patients had at least one comorbidity, with a median of three comorbidities. Largest differences between individuals with and without IBD were found for rheumatologic conditions, acid-related disorders, pain, bone diseases, migraines, cancer, and iron-deficiency anemia, whereas no significant differences between the two groups were found for diabetes, dementia, hyperlipidemia, glaucoma, gout, HIV, psychoses, and Parkinson’s disease after adjustments for a variety of covariates. Each increase in the morbidity status led to increased healthcare costs; rheumatologic conditions, acid-related disorders, and pain as the most frequent comorbidities more than doubled total costs in IBD patients.
CONCLUSIONWe found a considerably high prevalence of concomitant chronic diseases in IBD patients. This was associated with considerably higher healthcare costs, especially in the outpatient setting.
Polypharmacy for multiple chronic conditions (MCCs) poses an increasing challenge in people with HIV (PWH). This research explores medication adherence in PWH with MCCs before and during COVID-19.
...Kaiser Permanente Mid-Atlantic States.
Medical and pharmacy records of a continuously enrolled cohort (September 2018-September 2021) of adult PWH were used. To estimate medication adherence, monthly proportion of days covered (PDC) was measured individually for antiretrovirals (ARVs), diabetes medications (DMs), renin-angiotensin antagonists (RASMs), and statins (SMs) and combined into composite measures (CMs) with and without ARVs. Descriptive statistics, time-series models, and multivariable population-averaged panel general estimating equations were used to profile trends, effects, and factors associated with adherence.
The cohort (n = 543) was predominantly 51-64 years old (59.3%), Black (73.1%), male (69.2%), and commercially insured (65.4%). Two-thirds (63.7%) of patients were taking medications in 2 medication groups (ie, ARVs and either DMs, RASMs, or SMs), 28.9% were taking medications in 3 medication groups, and 7.4% were taking medications in all 4 medication groups. Overall, PDC for CMs without ARVs was 77.2% and 70.2% with ARVs. After March 2020, negative monthly trends in PDC were observed for CMs without ARVs (β = -0.1%, P = 0.003) and with ARVs (β = -0.3%, P = 0.001). For CMs with ARVs, Black race (aOR = 0.5; P < 0.001; ref: White) and taking medications for 3 medication groups (aOR = 0.8; P < 0.02; ref: 2) were associated with lower adherence.
Decreasing medication adherence trends were observed during the COVID-19 pandemic with variations among population subgroups. Opportunity exists to improve medication adherence for non-White populations and those taking medications for MCCs beyond ARVs.
Introduction
Using cross-sectional survey data, we assessed the association between chronic illness burden and health-related self-efficacy, evaluating whether patient-centered communication is ...associated with self-efficacy and if that relationship varies by chronic illness burden.
Methods
Data were from the Health Information National Trends Survey, a cross-sectional survey of the US adult population collected in 2012–2013 (
n
= 3630). Health-related self-efficacy was measured with the item: “Overall, how confident are you about your ability to take good care of your health?” and the prevalence of six chronic conditions and depression/anxiety was assessed. Patient-centered communication was measured as the frequency with which respondents perceived their healthcare providers allowed them to ask questions, gave attention to their emotions, involved them in decisions, made sure they understood how to take care of their health, helped them to deal with uncertainty, and if they felt they could rely on their healthcare providers to take care of their healthcare needs.
Results
Health-related self-efficacy was significantly lower among individuals with greater illness burden. In adjusted analysis, individuals who experienced more positive patient-centered communication reported higher levels of self-efficacy (
β
= 0.26,
P
< 0.0001); this association was strongest among those with greater illness burden.
Conclusion
Higher levels of self-efficacy were observed among patients reporting more positive patient-centered communication; the observed association was stronger among those with greater chronic illness burden.
Oral health influences the quality of life of older adults. Further, depression is negatively associated with oral health. However, little is known about this relationship among older adults with ...chronic health conditions. Additionally, since oral health and depression differ between genders, this study aimed to investigate the effect of transitions in depressive symptoms on oral health among older adults with chronic health conditions by gender.
We used data from the Korean Longitudinal Study of Aging (2020−2022). The study sample comprised 2836 older adults (1104 men; 1732 women). We adopted multiple linear regression to examine the association between depressive symptom transitions and oral health by gender.
The new onset depression symptoms were significantly associated with the deterioration of oral health in men (β = −5.4308) and women (β = −4.8328). Our study showed a gender-specific association between new onset depressive symptoms and particular domains of oral health. For men, the association was slightly more negative in psychosocial function (β = −2.1177) while women presented lower GOHAI scores in both the physical function domain (β = −1.8800) and the psychosocial function domain (β = −1.8801).
The data used in this study were self-reported via a survey; thus, self-report bias may be a relevant concern.
To prevent deterioration in oral health, depressive symptoms must be detected and addressed early among older adults with chronic conditions. This study underscores the importance of interventions that consider gender differences in the association between depressive symptoms and psychosocial and physical functioning.
•Depressive symptoms and oral health in older adults with chronic conditions are related.•New-onset depressive symptoms and persistence of depressive symptoms are associated with poorer oral health in both genders.•New-onset depressive symptoms related to poorer psychosocial function among men•New-onset depressive symptoms related to poorer psychosocial and physical function among women
To examine the impact of two key choices when conducting a network analysis (clustering methods and measure of association) on the number and type of multimorbidity clusters.
Using cross-sectional ...self-reported data on 24 diseases from 30,097 community-living adults aged 45-85 from the Canadian Longitudinal Study on Aging, we conducted network analyses using 5 clustering methods and 11 association measures commonly used in multimorbidity studies. We compared the similarity among clusters using the adjusted Rand index (ARI); an ARI of 0 is equivalent to the diseases being randomly assigned to clusters and 1 indicates perfect agreement. We compared the network analysis results to disease clusters independently identified by two clinicians.
Results differed greatly across combinations of association measures and cluster algorithms. The number of clusters identified ranged from 1 to 24, with low similarity of conditions within clusters. Compared to clinician-derived clusters, ARIs ranged from -0.02 to 0.24 indicating little similarity.
These analyses demonstrate the need for a systematic evaluation of the performance of network analysis methods on binary clustered data like diseases. Moreover, in individual older adults, diseases may not cluster predictably, highlighting the need for a personalized approach to their care.
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