Chronic Conditions The need for a comprehensive public health approach Olga McDaid PhD Scholar HRB PhD Programme for Health Services Research, Trinity College Dublin Supervisors Prof. Charles Normand, Dr.Alan Kelly, Dr.Susan Smith 1
Chronic condition burden in Ireland Population prevalence projections for selection of chronic conditions 2010-2020 Estimated increase in the number of adults aged 18+ who self-report a doctor-diagnosed condition in the previous 12 months. SLAN 2007 (ref study). Diabetes CHD HBP Stroke CAO N increase 30,000 24,000 103,000 6,000 19,000 % increase 28% 31% 24% 27% 23%
Public/population health perspective Changing demographics Growing population Ageing population – proportion of older people in Ireland expected to double by 2050 Chronic condition burden – 40% increase by 2020 Multimorbidity – defined as 2 or more co-occurring conditions in an individual ‘ the norm, not the exception ’ (Fortin et al, 2005)
Comorbidity OR Multimorbidity? Multimorbidity - an overarching global term referring to all conceptualisations of co-occurring conditions within an individual.
Multimorbidity Implications QoL, SRH, physical functioning, & premature mortality Healthcare utilisation, complexity, polypharmacy & costs
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25 CHRONIC CONDITIONS IN TILDA 2010 (50yrs +, n = 8,162) High Blood Pressure 32.4 % Heart murmur 4.6% Arthritis 27.6 % Anxiety 4.6% High cholesterol 24.7 % Stroke/TIA 3.6 % Falls/fracture 17.7 % Varicose Ulcer 3.5 % Chronic respiratory disease 12.2 % Hearing impairment 2.7 % Osteoporosis 9.3 % Other mental health conditions 2.4% Incontinence 9.2 % Vision impairment 2.1 % Angina/heart attack 8.5 % Alcohol or substance abuse 1.6 % Diabetes 8.0% Heart failure 1.1% Stomach ulcer 7.2% Memory disorders 0.7 % Abnormal heart rhythm 7.1 % Parkinson's 0.5 % Cancer 6.1 % Liver disease 0.5% Depression 5.2%
M ULTIMORBIDITY M EASURE IN TILDA Chronic conditions - physical diseases, mental health, geriatric syndromes and impairments Inclusion criteria Chronicity, prevalence, and inclusion in other measures. Produce consequences, or sequelae Quality Self-rated Physical of health function Life ‘fair or poor’ ADL or CASP 19 IADL
Multimorbidity prevalence ➟ Threshold multimorbidity (2+) – 53.8% ➟ Physical-mental health multimorbidity – 7.5% ➟ Mental health multimorbidity – 3.3% ➟ Concurrent condition counts 2 conditions = 21.0% (95% CI’s 20.0 -21.9%, n=1,731) 3 conditions = 14.1% (95% CI’s 13.3 -14.9%, n=1,151) 4 conditions = 8.8% (95% CI’s 8.1 -9.5%, n=697) 5 conditions = 4.7% (95% CI’s 4.2 -5.2, n=378) 6+ conditions = 5.1% (95% CI’s 4.6 -5.6%, n=399)
Population prevalence of all type multimorbidity (50 yrs+)
90 years 89 years 88 years 87 years 86 years 85 years 84 years 83 years 82 years 81 years 80 years 79 years 78 years 77 years 76 years 75 years 74 years 73 years 72 years 71 years 70 years 69 years 68 years 67 years 66 years 65 years 64 years 63 years 62 years 61 years 60 years 59 years 58 years 57 years 56 years 55 years 54 years 53 years 52 years 51 years 50 years 4 3 2 1 0 1 2 3 4 Male Female Mean number of conditions by sex and age sex and age (TILDA 2010)
Prevalence of concurrent multimorbidity by deprivation (SAHRU deprivation deciles 1=most affluent, 10=most deprived) 30 25 20 Percentage % 1 & 2 3 & 4 15 5 & 6 7 & 8 10 9 & 10 5 0 None One Two Three Four Five Six + Number of conditions
Multimorbidity Prevalence Threshold multimorbidity (2+) • Rural areas • Living alone • Permanently sick and disabled Physical-mental health multimorbidity • Permanently sick and disabled • Separated or divorced • Employment (self-employment) protective
Cluster analysis Dendrogram Legend C1 Angina C2 Heart attack C3 Heart failure C4 Stroke C5 Trans ischaemic attack C6 A heart murmur C7 An abnormal heart rhythm C8 Diabetes C9 High blood pressure C10 High cholesterol C11 Falls C12 Fractures C13 Incontinence C14 Vision impairment C15 Hearing impairment C16 Chronic lung disease C17 Asthma C18 Osteoarthritis C19 Rheumatoid arthritis C20 Unclassified arthritis C21 Osteoporosis C22 Cancer C23 Stomach ulcers C24 Varicose ulcers C25 Alcohol or substance abuse C26 Anxiety C27 Depression C28 Other mental health conditions
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Effect of Multimorbidity on healthcare services Healthcare services • GP visits • Outpatient visits • Emergency Department • Hospital Stays • Polypharmacy Two-part modeling process controlled for range of covariates Findings: • Substantial burden of care • Multimorbidity is a significant driver of healthcare in Ireland, across all healthcare outcomes examined, even after controlling for age effects and other need factors such as disability and frailty. • In general, appears to be a cascade effect of increasing levels of multimorbidity on HCU, however the independent effect on propensity of service use and intensity of use varies according to type of healthcare services
Predicted probability of propensity to visit a GP by increasing levels of multimorbidity
Predicted probability of intensity of GP use by increasing levels of multimorbidity 10/10/2013
The need for a comprehensive public health approach High burden of multimorbidity at a population level in Ireland - associated with negative impacts on individuals and society. • Focus on ‘silo’s of conditions or broader outcome constructs • Parity of mental and physical health conditions • Need to design effective programmes to prevent/delay the onset of complex health status in later life • Accurate estimates of population prevalence and incidence as well as condition patterns or “clusters” – provide a more informed approach to chronic condition burden and prevention at a population level • Design an appropriate healthcare system to adapt to increasing population health demand and projected complexity – informed by a population health approach to chronic condition
L IMITATIONS AND N EXT STEPS … Data are self-reported Severity of conditions Economic data is limited Predictors of multimorbidity – longitudinal data Mental & physical health – parity Social patterning of multimorbidity Comparative population level data Patient intervention Clinical and policy guidelines 10/10/2013
Thank you for listening… Contact: mcdaido@tcd.ie Acknowledgements TILDA - Funded by - Department of Health (ROI), The Atlantic Philanthropies, Irish Life. Thanks to: Brendan Whelan (TILDA) Howard Johnston (Health Atlas) & Davida de la Harpe (HSE) Alan Kelly & Conor Teljeur (SAHRU) This work was funded by the Health Research Board in Ireland under Grant No. PHD/2007/16.
Clinical perspective • Management of complex patients • Increased prescribing • Treatment regimes based on RCTs that have excluded complex patients • Healthcare systems adopt a vertical approach • Fragmentation of care • Investigations driven by a focus on co-morbidity 23
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