Comorbidities in the Context of Care Transitions

Janet H. Van Cleave, PhD, MBA, MSN, ACNP-BCHarleah G Buck, PhD, RN, CHPNSusan Lysaght, MA, MS, GNP-BC

Melissa O’Connor, PhD, MBA, RN, COS-C Mary D. Naylor, PhD, RN, FAAN

Janet H. Van Cleave, PhD, MBA, MSN, ACNP-BCHarleah G Buck, PhD, RN, CHPNSusan Lysaght, MA, MS, GNP-BC

Melissa O’Connor, PhD, MBA, RN, COS-C Mary D. Naylor, PhD, RN, FAAN

1

NEWCOURTLAND CENTER FOR TRANSITIONS AND HEALTHUniversity of Pennsylvania School of Nursing

Support

• University of Pennsylvania School of Nursing NewCourtland Center for Transitions and Health

• University of Pennsylvania Pre and Post-Doctoral Fellowships, National Institutes of Health, T32NR009356, Individualized Care for At-Risk Older Adults

• John A. Hartford Foundation Building Academic Geriatric Nursing Capacity Program

NewCourtland Center Comorbidity Research Teams

Evolutionary • Salimah Meghani

(Chair)• Leah Buck• Eeeseung Byun• Joan Davitt• Michael Fachko• Melissa O’Connor• Janet Prvu Bettger• Minkyoung Song• Christine Tocchi

Dimensional Analysis• Rebecca Trotta (Chair)• Janet Van Cleave (Co-

Chair)• Susan Lysaught• Melinda Steis• Becky Lorenz• Sarah Kagan-Expert

Consultant

Comorbidity is a Significant Health Problem

• Individuals with comorbidities– 28% of Americans– 3 out of 4 individuals over the age 65

• Increasing number of persons living with comorbidities• 1987: 31% Medicare beneficiaries with 5 or more comorbidities • 2002: ~50% of all Medicare beneficiaries with 5 or more comorbidities

(Anderson, 2010; MedPAC, 2010; U.S. Dept Health & Human Services, 2010)

Comorbidities Financially Challenge the Health Care System

•Driving force of the United States health care spending•Individuals with comorbidities account for:

– 98% of Medicare costs – Over 60% of total health care expenditures

• Expenditures increase with each additional comorbidity

(Anderson, 2010; U. S. Dept of Health & Human Services, 2010)

Comorbidities Medically Challenge the Health Care System

• Increase mortality and limit function• Inappropriate care unaligned with patient’s

goals and preferences• Fractured care in multiple health care sites(NQF, 2012; Dept of Health & Human Services, 2010)

Need for Research

• U.S. Department of Health and Human Services. Multiple Chronic Conditions—A Strategic Framework: Optimum Health and Quality of Life for Individuals with Multiple Chronic Conditions. Washington, DC. December 2010.

• Goal 4: Need for research to benefit individuals with comorbidities – Advance knowledge – Develop interventions– Develop systems

What is Comorbidity?

• Multiple terms used in health care to describe comorbidity(ies)

• Multiple outcomes• Temporal components

(Feinstein, 1970; Yancik et al., 2007; Vogeli et al., 2007; Wolff, Starfield, & Anderson, 2002; Karlamangla et al., 2007; Weiss, 2007)

Research Question

• What is the definition of comorbidity(ies) – Chronically ill adults – Transitioning through acute episodes of illness

Today’s Symposium

• The Science of Comorbidities: Current Quandaries and Future Recommendations

• Concept Analyses– Empirical Article Selection for Concept Analysis– Dimensional Analysis: Comorbidities in the Face of

Transitions– Evolutionary Analysis: Comorbidity in Patients

Undergoing Transitions

• Closing Remarks

Empirical Article Selection for Concept Analysis of Patients with Comorbidities Undergoing Care Transitions

Janet H. Van Cleave1

Harleah G. Buck2

Salimah Meghani3

Janet Prvu-Bettger4

Mary D. Naylor3

1New York University, 2Pennsylvania State University, 3University of Pennsylvania, 4Duke University

Purpose

• Decisions regarding search strategies and article selection influence concept analysis findings and impact knowledge development

• Careful planning and explicit criteria decrease the potential to introduce study bias

• The purpose of this presentation is to describe our methods to capture a heterogeneous, representative body of empirical literature for two concept analyses

Literature Search

Goal: Transparent literature searchPreliminary literature searchesDeveloped and finalized literature search syntax

Buck, H.G., Meghani, S., Bettger, J.P. et al., 2012. The use of comorbidities

among adults experiencing care transitions: a systematic review and evolutionary analysis of empirical literature. Chronic Illness.

Initial Inclusion Criteria

• Years of publication: 1965-present • Age: Adults 19+ • Human • English language • Research Articles • Transition: There should be an acute event with at least one

transition from high to low or low to high acuity care. • United States (both VA and non-VA)

Literature Search

Four databases MedlineCinahlPsycINFOWeb of Science - Social Science

Uploaded into Refworks 5,917 references

Representative Heterogeneous Database

• Random selection of 650 articles (50 articles per working group member)

• Review articles according to inclusion criteria

Initial Review

• Selected 98 articles• Refinement of definition of transition

Refinement of Parameters of Transitions

• An acute episode of chronic illness with at least one transition

• Transitional settings (i.e., in the context of low to high acuity or high to low acuity care)

• Related variables directly or indirectly accounted for in the analysis of transitional outcomes (cost, re-hospitalization, functional status, and QOL)

Continued Review of Articles

• Final review for uniformity and fidelity to inclusion criteria

• Final database: 60 articles

Search from 1965 – July, 2009

Records Identified by Database Search:Medline (n=4,660),CINAHL (n=82),PsychINFO (n=645)ISI Web of Science-Social Science (n=1,489)

5, 917 records after duplicates removed

10% records randomly selected and screened for inclusion (n=650)

Final set of articles included in

analysis (n=60)

Inclusion criteria:Empirical studiesPublished in EnglishPeer-reviewed journalsHumans over 19 years of ageU.S. health care setting

Excluded records (n=552)

Excluded abstracts (n=38)

Abstracts screened for

inclusion (n=98)

Selection of Empirical Articles

Empirical Articles

• Published between 1990 and 2009

32%

5%63%

Articles

ProspectiveRandomized Clin-ical TrialRetrospective

Description of Empirical Articles

75%

12%

8%5%

Articles

Disease DiagnosesTrauma/SurgicalPsychiatricOlder Adults

Empirical Articles

• 33 (55%) addressed higher to lower acuity transitions

• 27 (45%) featured lower to higher acuity transitions

Summary: Comorbidities in the Context of Care Transitions

New Approaches

• Patient focused– Loss of the voice of the individual– Individual experience

• Measuring risk for individuals– Predict or explain outcomes on individual, disease,

and system levels– Risk over time– Co-existing vs. co-occurring

New Approaches

• Relationships– Among comorbidities– Among individuals, comorbidities, and

consequences• Complexity

– Synergism vs. relative importance vs. patterns– Number, nature, and extent

New Approaches

• Importance of terminology– Nosology– Principality– Dynamicity

Questions

Thank you

NEWCOURTLAND CENTER FOR TRANSITIONS AND HEALTHUniversity of Pennsylvania School of Nursing