Context of Thesis Topic Introduction

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2 Cntext f Thesis Tpic Intrductin

3 Multimrbidity (MM) = Cexistence f multiple chrnic diseases within an individual, where n single disease hlds pririty ver any ther c-ccurring diseases 1-4 Cmrbidity = Cexistence f multiple chrnic diseases within an individual, where an index disease hlds pririty ver any ther c-ccurring diseases 4-5 Chrnic Disease Chrnic Disease Index Disease Chrnic Disease Cmrbidity vs. Multimrbidity Chrnic Disease Chrnic Disease Chrnic Disease Chrnic Disease Patient Surce: Byd and Frtin, 2010 Patient

4 Multimrbidity (MM) = Cexistence f multiple chrnic diseases within an individual, where n single disease hlds pririty ver any ther c-ccurring diseases 1-4 Time Patient Chrnic Disease Chrnic Disease Chrnic Disease Chrnic Disease Time Patient Chrnic Disease Chrnic Disease Chrnic Disease Time Chrnic Disease Chrnic Disease Chrnic Disease Chrnic Disease Chrnic Disease Patient

5 Multimrbidity in Primary Health Care (PHC) Prevalence f multimrbidity has ranged frm 34% t 95% amng adult patients 6-7 Prevalence f multimrbidity has ranged frm 55% t 98% amng lder adult patients 8-10 Surce: McPhail, 2016

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7 Measuring Multimrbidity in Epidemilgical Research N gld standard measure fr multimrbidity, particularly within electrnic medical recrd data Understanding the Patterns f Multimrbidity Internatinal studies have fund distinct patterns f chrnic disease clustering amng adult and lder adult patients 9, 14 Cmparable understanding in Canadian PHC still needed Explring the Natural Histry f Multimrbidity Fllwing PHC patients ver time will help t understand hw patients prgress int mre cmplex clinical prfiles 16-18

8 Cntext f Thesis Tpic Objectives

9 Objective One: T describe the incidence and prevalence f multimrbidity amng adult PHC patients Including EMR data cllected frm 2003 t 2013 Objective Tw: T examine the patterns and prgressin f multimrbidity ver time amng adult PHC patients Including specific sequence f diagnses

10 Cntext f Thesis Tpic Data Surce

11 Currently Hlds > 1.5 Millin Patient-Level Recrds Hlds Lngitudinal, Clinical Data frm PHC Prviders in Eleven Reginal Netwrks in Eight Prvinces British Clumbia, Alberta (tw netwrks), Manitba, Ontari (fur netwrks), Quebec, Nva Sctia, Newfundland and Labradr Patient-Level Electrnic Data Recrded Fr: Patient encunters, labratry tests and results, prescribed medicatin, prblem lists and clinical diagnses My Extract f Data: Q Extracted as f September 30 th, 2013

12 Cntext f Thesis Tpic Methdlgy

13 1 Hypertensin 11 Strke r Transient Ischemic Attack 2 Obesity 12 Thyrid Prblem 3 Diabetes Mellitus 13 Kidney Disease r Failure 4 Chrnic Obstructive Pulmnary Disease r Asthma 14 Osteprsis 5 Hyperlipidemia 15 Dementia (All Frms) 6 Cancer (All Types) 16 Musculskeletal Prblem 7 Cardivascular Disease 17 Stmach Prblem 8 Heart Failure 18 Cln Prblem 9 Anxiety r Depressin 19 Liver Disease 10 Ostearthritis r Rheumatid Arthritis 20 Urinary Prblem Assciated ICD-9/ICD-10 Diagnstic Cdes Currently Underging Validatin Nichlsn et al. (2015) Jurnal f Cmrbidity

14 Cmbinatins Unrdered Clusters f Multiple Chrnic Disease Example: Cancer & Dementia & Anxiety r Depressin N Specific Anxiety r Depressin & Cancer & Dementia Sequence Permutatins Ordered Clusters f Multiple Chrnic Disease Example: Cancer >> Dementia >> Anxiety r Depressin Specific Sequence Anxiety r Depressin >> Cancer >> Dementia Required Multimrbidity Cluster Analysis Tl Develped

15 Inclusin Criteria Data Management Statistical Techniques 1 in-ffice encunter recrded in EMR 18 years f age at first recrded encunter date Overall Sample Size = 367,743 Adult PHC Patients Identified all first ccurrence chrnic disease diagnses patients received Identified crrespnding date f diagnsis Identified patients with 2 and 3 chrnic diseases Cmputed all detected clusters using JAVA Cnducted descriptive analyses (e.g., incidence and prevalence) and multivariable analyses (e.g., multilevel recurrent event survival analysis) using STATA

16 Cntext f Thesis Tpic Findings

17 8.9% 14.0% 10.2% 22.0% N = 367, % 24.8% Ttal Number f Chrnic Diseases Adult PHC Patients, 1 In-Office Visit List f 20 Chrnic Disease Categries Observatin Perid =

18 Identified new cases f multimrbidity frm 2003 t 2013 Analyses stratified by tw key definitins f multimrbidity

19 Each cmbinatin represents mutually exclusive clusters Analyses als stratified by ttal number f chrnic diseases

20 Each cmbinatin represents mutually exclusive clusters Analyses als stratified by ttal number f chrnic diseases

21 Each permutatin represents mutually exclusive clusters Analyses als stratified by ttal number f chrnic diseases

22 Each permutatin represents mutually exclusive clusters Analyses als stratified by ttal number f chrnic diseases

23 *Mutually exclusive prfiles & diseases are nt causally related Multimrbidity Amng Adults in Primary Health Care

24 *Mutually exclusive prfiles & diseases are nt causally related Multimrbidity Amng Adults in Primary Health Care

25 Results suppressed amng the mst frequent permutatins fr male patients aged years with multimrbidity (n= 2,624)

26 Highlighting key independent variables frm analysis 0.82 ( ) < 1.21 ( ) 0.98 ( ) 0.69 ( ) ( ) < ( )

27 Cntext f Thesis Tpic Discussin

28 Prevalence estimates f multimrbidity amng adult PHC patients in Canada is cnsistent with internatinal literature Surce: Vilán et al., 2014

29 Prevalence estimates f multimrbidity amng adult PHC patients in Canada is cnsistent with internatinal literature Adult PHC patients with multimrbidity are living with clusters that becme increasingly unique, especially when a specific sequence is examined Careful use f this infrmatin in clinical training culd help create simulated multimrbidity-based patient vignettes f the mst cmmn/uncmmn clusters using real data These results prvide empirical evidence t supprt the need fr patient- and family-centered care fr individuals living with multimrbidity

30 1. Prvided insight int prevalence, patterns and prgressin f multimrbidity amng adult PHC patients in Canada 2. Accessed imprtant surce f lngitudinal clinical data frm the nly pan-canadian PHC EMR database 3. Addressed the methdlgical challenges f using an EMR database t study cmplex issue f multimrbidity 1. Operatinalized multimrbidity using cunt number f chrnic diseases, which des nt accunt fr disease severity 2. Onging lack f rbust sciecnmic and mdifiable risk factr data, which can be imprtant in disease prgressin 3. Ultimately, data are cllected fr clinical, nt research, purpses

31 Explring Multimrbidity Using Tw Natinal Databases Examining Therapeutic Cmpetitin in Plypharmacy & Cncrdance Between Multimrbidity, Frailty and Disability

32 Multimrbidity The Symptm Amng Adults f Fatigue in Primary in Primary Health Care Care PhD Cmmittee: PDF Cmmittee: Dr. Amardeep Thind Dr. Parminder Raina Dr. Amanda Terry Dr. Lauren Griffith Dr. Martin Frtin Dr. Tyler Williamsn Department f Epidemilgy & Bistatistics Schulich Schl f Medicine & Dentistry Canadian Institutes f Health Research Canadian Primary Care Sentinel Surveillance Netwrk Patient-Centered Innvatins fr Persns with Multimrbidity Canadian Lngitudinal Study n Aging

33 1. Feinstein AR. The pre-therapeutic classificatin f c-mrbidity in chrnic disease. Jurnal f Chrnic Diseases. 1970;23: Feinstein AR. Clinical judgement. New Yrk, NY: The Williams and Wilkins Cmpany; Frtin M, Lapinte L, Hudn C, Vanasse A. Multimrbidity is cmmn t family practice: is it cmmnly researched? Canadian Family Physician. 2005;51: van den Akker M, Buntinx F, Knttnerus AJ. Cmrbidity r multimrbidity: what s in a name? A review f literature. Eurpean Jurnal f General Practice. 1996;2: Byd CM, Frtin M. Future f multimrbidity research: hw shuld understanding f multimrbidity infrm health system design? Public Health Reviews. 2010;32(2): Frtin M, Stewart M, Pitras M-E, Almirall J, Maddcks H. A systematic review f prevalence studies n multimrbidity: tward a mre unifrm methdlgy. Annals f Family Medicine. 2012;10(2): Stewart M, Frtin M, Britt HC, Harrisn CM, Maddcks HL. Cmparisns f multi-mrbidity in family practice - issues and biases. Family Practice. 2013;30: Marengni A, Angleman S, Melis R, Mangialasche F, Karp A, Garmen A, et al. Aging with multimrbidity: a systematic review f the literature. Ageing Research Reviews. 2011;10: Sinnige J, Braspenning J, Schellevis F, Stirbu-Wagner I, Westert G, Krevaar J. The prevalence f disease clusters in lder adults with multiple chrnic diseases: a systematic literature review. PLS One. 2013;8(11):e Salive ME. Multimrbidity in lder adults. Epidemilgic Reviews Rev. 2013;35(1): Diederichs C, Berger K, Bartels DB. The measurement f multiple chrnic diseases - a systematic review n existing multimrbidity indices. Jurnal f Gerntlgy. Series A, Bilgical Sciences and Medical Sciences. 2011;66(3): Almirall J, Frtin M. The cexistence f terms t describe the presence f multiple cncurrent diseases. Jurnal f Cmrbidity. 2013;3: Frtin M, Subhi H, Hudn C, Bayliss EA, van den Akker M. Multimrbidity s many challenges: time t fcus n the needs f this vulnerable and grwing ppulatin. British Medical Jurnal. 2007;334: Prads-Trres A, Calderón-Larrañaga A, Hancc-Saavedra J, Pbladr-Plu B, van den Akker M. Multimrbidity patterns: a systematic review. Jurnal f Clinical Epidemilgy. 2014;67:

34 15. France EF, Wyke S, Gunn JM, Mair FS, McLean G, Mercer SW. Multimrbidity in primary care: A systematic review f prspective chrt studies. British Jurnal f General Practice. 2012;62(597):e Mercer SW, Salisbury C, Frtin M, eds. ABC f multimrbidity. Oxfrd, UK: BMJ Publishing Grup Limited; Mrris RL, Sanders C, Kennedy AP, Rgers A. Shifting pririties in multimrbidity: a lngitudinal qualitative study f patient s priritizatin f multiple cnditins. Chrnic Illness. 2011;7(2): Mercer SW, Guthrie B, Furler J, Watt GC, Hart JT. Multimrbidity and the inverse care law in primary care. British Medical Jurnal. 2012;344:e Pefy AJK, Brnskill SE, Gruneir A, Calzavara A, Thavrn K, Petrsyan Y, et al. The increasing burden and cmplexity f multimrbidity. BMC Public Health. 2015;15: Smith S, O Dwd T. Chrnic diseases: what happens when they cme in multiples? British Jurnal f General Practice. 2007;57(537): Tinetti ME, Basu J. Research n multiple chrnic cnditins: where we are and where we need t g. Medical Care. 2014;52(3):s Byd CM, Darer J, Bult C, Fried LP, Bult L, Wu AW. Clinical practice guidelines and quality f care fr lder patients with multiple cmrbid diseases: Implicatins fr pay fr perfrmance. Jurnal f the American Medical Assciatin. 2005;294(6): Gill A, Kuluski K, Jaakkimainen L, Naganathan G, Upshur R, Wdchis WP. Where d we g frm here? Health system frustratins expressed by patients with multimrbidity, their caregivers and family physicians. Healthcare Plicy. 2014;9(4): CPCSSN. Canadian Primary Care Sentinel Surveillance Netwrk Available frm: CLSA. Canadian Lngitudinal Study n Aging Available frm: Nichlsn K, Terry AL, Frtin M, Williamsn T, Bauer M, Thind A. Examining the Prevalence and Patterns f Multimrbidity in Canadian Primary Healthcare: A Methdlgic Prtcl Using a Natinal Electrnic Medical Recrd Database. Jurnal f Cmrbidity. 2015;5:

35 Thank-Yu! Questins r Cmments?

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39 Identified all cmbinatins and permutatins in sample f adult PHC patients with multimrbidity Available fr use by external researchers wh are interested in multimrbidity patterns This cmputatinal analyses can be adapted t variatins in research methdlgy (e.g., different definitins f multimrbidity r type f database)

40 The input data file that hlds disease infrmatin fr patients is structured as: d 1, t 1, d 2, t 2,..., t n-1, d n Where, d i = ne f twenty chrnic disease categries t i = time (in days) between tw cnsecutive diagnses fr that patient. The JAVA sftware then systematically: a) cunts the number f times that the pattern d 1, d 2,..., d n ccurs, in any rder b) cunts the number f times that the pattern d 1, d 2,..., d n ccurs, in rder Where, a) = cmbinatins b) = permutatins

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