THE RELATIONSHIP BETWEEN ACTIVITIES OF DAILY LIVING AND MULTIMORBIDITY. A VIEW FROM TELECARE

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THE RELATIONSHIP BETWEEN ACTIVITIES OF DAILY LIVING AND MULTIMORBIDITY. A VIEW FROM TELECARE Edurne Alonso Morán Biostatician Researcher Collaborative Research of Osatek, SA, Public Society of the Basque Government

Introduction The Public Telecare Service of the Basque Government (betion) provides home care for dependent and older people through a technological device that guarantees a permanent connection with an interdisciplinary team of professionals who are trained in remote socio health care. One of the main objectives of betion is to promote the permanence of their users in their usual social environment. Moreover, this connection with health care devices allows implementing shared information systems with health and social data, which enable a characterization of the attended population and the development of integrated models for health and social provision.

The users of telecare service The users of telecare service have at least one of the following characteristics: People over 75 who live alone People over 65 who are in a situation of acknowledged dependency or in situation of vulnerability recognized by social services People with intellectual, physical or sensorial disability and recognized dependency at any degree People who have a diagnosed mental illness and present a situation of recognized dependency or risk of social exclusion. In 2013, the 77.57% of the telecare population were aged above 80 years, 80.69% of users were female and 65% livedalone.

Objectives of the study Describing the quality of life of users of public telecare service collected by the EQ 5D 3L questionnaire (EuroQol) Establishing the relationship between quality of life and multimorbidity. Analyzing the relative impact of a potentially large number of coexisting conditions on overall Health Related Quality of Life (HRQOL) Analyzing the effects of different conditions in the specific dimensions of HRQOL (mobility, self care, daily activities, pain/discomfort and depression/anxiety).

Methods It was extracted information from the stratification database of the Basque Country (PREST) of 1,125 users of betion. PREST has been created to classify all Basque citizens based on their future health care needs in a hundred mutually exclusive groups, Adjusted Clinical Groups (ACG), provided by the case mix developed at Johns Hopkins University (Baltimore). This database contains demographic, socioeconomic (depriva on index of the residence area) and clinical variables, from data registered in the Minimum Basic Data Set (MBDS) and annotations in electronic health records of specialist care and primary care. To detect chronic disease, it was used information about diagnoses and prescriptions. For HRQOL, it was utilized the EQ 3D questionnaire by telephone between the users of betion. Some social variables were also collected

Results: Socio demographic data Sex N % Male 201 17.9% Female 924 82.1% Age band N % 65 74 137 12.2% 75 79 304 27.0% 80 84 401 35.6% 85+ 283 25.2% Civil status N %. 363 32.3% Married 184 16.4% Divorced or Separated 15 1.3% Single 44 3.9% Widow/er 519 46.1% Residence unit N % Live alone 745 66.2% Live with 1 person 319 28.4% Live with 2 people 38 3.4 % Live with 3 or more people 23 2.0% 82% were women. About 88% were older than 75 years. 46% were widow. 66% lived alone.

Results: Related home data 1.6% 1.3% Type of building 2.8% 12.8% Missing values Neighboring buildings 0.3% Building condition 13.8% Single family urban dwellings Missing values Correct 81.4% Single family isolated dwellings Sheltered housing 86.0% Deficient Heating system 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% 2.7% 10.6% 0.8% 13.4% 15.0% 2.0% 52.0% 2.3% 0.4% 0.8% 0.1%

Results: Users multimorbidity 7.00 Average of chronic conditions Average of chronic conditions by residence unit 6.00 5.00 4.00 5.7 5.7 4.9 5.1 4.8 5.0 4.7 4.1 Live with 3 or more people Live with 2 people 6.0 6.2 3.00 2.00 Live with 1 person 5.1 1.00 0.00 65 74 75 79 80 84 85+ Males Females Live alone 4.4 0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0 The average of chronic diseases is higher among males and this rate decreases with age. This fact is consistent with the type of population assisted by the public telecareservice.wefoundthatuserswholivewithmorepeopleathomehad more chronic conditions.

Results: Prevalence of chronic conditions From a list of 52 chronic conditions, we have represented here those whose prevalence is greater than 3%. Prevalence (%) Prevalence (%) Chronic conditions General Males Females Chronic conditions General Males Females Hypertension 80.1 81.3 79.8 Heart failure 10.6 15.8 9.5 Anxiety & other neurotic, stress related & somatoform disorders 43.0 26.8 46.5 Ischemic Heart Disease 10.1 20.7 7.8 Emphysema, chronic bronchitis, Prostatic hypertrophy 31.0 COPD 9.9 23.0 6.9 Degenerative joint disease 30.9 19.3 33.4 Chronic renal failure 9.6 16.5 8.0 Treated dyspepsia 30.3 29.2 30.5 Low back pain 9.2 5.8 10.0 Diabetes 25.3 29.5 24.4 Deafness, hearing loss 8.5 9.0 8.5 Depression 25.2 17.1 27.1 Dementia 8.4 9.3 8.1 Osteoporosis 18.9 3.3 22.3 Diverticular disease of intestine 7.9 7.9 7.9 Atrial fibrillation 17.7 26.5 15.9 Peripheral neuropathy, neuritis 7.2 8.7 6.8 Glaucoma 16.2 11.8 17.1 Blindness & low vision 6.9 7.4 6.9 Cerebro vascular disease 14.8 21.9 13.4 Rheumatoid arthritis and autoimmune and connective tissue diseases 5.5 4.4 5.7 Chronic heart disease, others 12.5 19.4 10.9 Parkinson s disease 5.4 8.9 4.8 Hypotiroidism 11.2 8.2 12.0 Asthma(currently treated) 5.3 4.8 5.5 Malignancies 11.0 23.0 8.5 Gout 3.6 12.7 1.6

Results: HRQOL by each dimension Mobility Daily activities 1% 60% 23% 5% 39% Self care 72% Don't have Have some Have severe Don't have Have some Have severe 43% 13% 19% 50% 44% Pain/discomfort 31% Don't have Have some Have severe Don't have Have some Have severe 33% Anxiety/depression 9% 58% Don't have Have some Have severe

Results: HRQOL by sex and age band Dimensions of EuroQol EQ VAS Males (N=201) Mean SD 65 74 (N=32) 0,64 0,26 75 79 (N=51) 0,58 0,27 80 84 (N=66) 0,64 0,25 85 o más (N=52) 0,70 0,24 Total 0,64 0,25 Females (N=924) Mean SD 65 74 (N=105) 0,55 0,24 75 79 (N=253) 0,60 0,25 80 84 (N=335) 0,60 0,26 85 o más (N=231) 0,58 0,25 Total 0,59 0,25 Since the average of chronic conditions decreases with the age in this population, in males, the oldest group reported the best values of HRQOL. In females, the youngest group reported the worst values of HRQOL.

Results: Multimorbidity and HRQOL Women obtained worse values on the scale of HRQOL than men. Each chronic condition rested 2.5 points to EQ VAS index. Age was not significant in the model. The more members in the family the worst values were obtained. R square: 13.49% EQ VAS*100 Beta Coef. Stand. Error [Confidence Interval 95%] P value Sex Males (ref) Females 9.3 1.9 13.0 5.6 <0.001 Number of chronic conditions 2.6 0.3 3.1 2.0 <0.001 Age band 65 74 (ref) 74 79 3.6 2.4 1.2 8.4 0.14 80 84 3.3 2.3 1.3 7.9 0.16 Over 84 2.7 2.5 2.2 7.5 0.28 Residence unit Live alone Live with 1 person 11.2 1.6 14.3 8.0 <0.001 Live with 2 people 13.9 4.0 21.7 6.1 <0.001 Live with 3 or more people 1.7 5.0 11.6 8.2 0.73 Intercept 80.5 2.9 74.7 86.2 <0.001

Results: Chronic conditions and HRQOL R square: 15.92% Regression: VAS*100=Sex+age band+chronic conditions (prevalences over 1%) It is represented all variables which are statistically significant EQ VAS*100 Beta Coef. Stand. Error [Confidence Interval 95%] P value Sex Males (ref) Females 6.2 2.3 10.7 1.6 0.0 Chronic conditions Ischemic Heart Disease 6.2 2.6 11.3 1.2 0.0 Rheumatoid arthritis and autoimmune and connective tissue diseases 8.9 3.2 15.1 2.7 0.0 Cerebro vascular disease 4.1 2.1 8.3 0.0 0.1 Peripheral vascular disease 10.5 5.4 21.1 0.0 0.1 Heart failure 9.1 2.7 14.4 3.8 <0.001 Dementia 5.4 2.6 0.2 10.5 0.0 Parkinson s disease 13.4 3.2 19.7 7.2 <0.001 Chronic liver or pancreatic disease 10.1 5.0 19.9 0.3 0.0 Paralysis or muscular dystrophy 11.1 4.5 19.9 2.3 0.0 Degenerative joint disease 6.3 1.6 9.4 3.2 0.0 Anxiety & other neurotic, stress related & somatoform disorders 3.0 1.5 6.0 0.1 0.1 Depression 7.0 1.7 10.4 3.6 0.0 Treated dyspepsia 5.4 1.6 8.6 2.2 <0.001 Low back pain 6.1 2.5 11.0 1.2 0.0 Intercept 75.2 3.3 68.8 81.6 <0.001

Results: Ranking of worst conditions in terms of QoL (means) EQ VAS EQ VAS Daily Pain/ Anxiety/ Chronic conditions EQ VAS Males Females Mobility Self care activities Discomfort Depression Alcohol 0,44 0,79 0,32 1,75 2,00 2,50 1,75 1,25 Parkinson s disease 0,46 0,44 0,46 1,89 1,84 2,10 1,89 1,59 Paralysis or muscular dystrophy 0,47 0,46 0,48 1,97 1,74 2,16 1,77 1,42 Heart failure 0,47 0,54 0,45 1,82 1,52 1,99 2,10 1,55 Chronic liver or pancreatic disease 0,48 0,80 0,42 1,79 1,58 2,00 2,17 1,71 Peripheral vascular disease 0,49 0,57 0,38 1,82 1,36 2,14 2,09 1,64 Rheumatoid arthritis and autoimmune and connective tissue diseases 0,49 0,33 0,52 1,76 1,55 1,85 2,16 1,58 Low back pain 0,51 0,47 0,52 1,75 1,41 1,83 2,12 1,64 Ischemic Heart Disease 0,52 0,59 0,48 1,73 1,53 1,88 2,02 1,55 Inflammatory bowel disease 0,52 0,39 0,56 1,62 1,23 2,00 2,23 1,46 Depression 0,53 0,62 0,51 1,67 1,43 1,82 2,02 1,78 Irritable bowel syndrome 0,53 0,79 0,51 1,63 1,19 1,81 2,06 1,81 Chronic heart disease, others 0,53 0,56 0,51 1,67 1,51 1,87 1,96 1,51 Disorders of the inmune system 0,53 0,47 0,54 1,61 1,44 1,78 2,06 1,56 Diverticular disease of intestine 0,54 0,64 0,52 1,69 1,44 1,85 1,94 1,53 Cerebro vascular disease 0,54 0,57 0,53 1,72 1,48 1,85 1,87 1,52 Degenerative joint disease 0,54 0,58 0,54 1,72 1,43 1,76 2,04 1,54 Treated dyspepsia 0,55 0,61 0,53 1,70 1,38 1,76 2,03 1,57 Asthma(currently treated) 0,55 0,58 0,54 1,67 1,37 1,75 2,03 1,63 Chronic renal failure 0,55 0,59 0,53 1,76 1,47 1,87 1,88 1,41 Emphysema, chronic bronchitis, COPD 0,55 0,59 0,53 1,73 1,40 1,77 1,93 1,47 Deafness, hearing loss 0,55 0,70 0,52 1,69 1,40 1,65 1,96 1,69

Results: Mobility and chronic conditions Treated dyspepsia Peripheral vascular disease Parkinson s disease Paralysis or muscular dystrophy Low back pain Heart failure Dementia Degenerative joint disease Cerebro-vascular disease 0 5 10 15 20

Results: Self care and chronic conditions Rheumatoid arthritis and autoimmune and connective tissue diseases Parkinson s disease Paralysis or muscular dystrophy Depression Degenerative joint disease Chronic liver or pancreatic disease Chronic heart disease, others 2 4 6 8

Results: Daily activities and chronic conditions Peripheral vascular disease Parkinson s disease Paralysis or muscular dystrophy Heart failure Depression 4 8 12 16

Results: Pain/Discomfort and chronic conditions Treated dyspepsia Rheumatoid arthritis and autoimmune and connective tissue diseases Peripheral vascular disease Low back pain Ischemic Heart Disease Heart failure Female Dementia Degenerative joint disease Anxiety & other neurotic, stress related & somatoform disorders 0 5 10 15 20

Results: Anxiety/Depression and chronic conditions Peripheral vascular disease Over 84 Female Depression Anxiety & other neurotic, stress related & somatoform disorders 80-84 1 2 3

Limitations A frequent situation for some chronic diseases is that the administrative databases only contain records of morbidity attended, so information on diseases and conditions is excluded for which patients do not require assistance. Although a universal insurance system like ours barriers to accessibility are lower than elsewhere. Moreover,wehavetotakeintoaccountthat questionnaires are subject to a subjective perspective.

Conclusions I The most prevalent chronic disease among men were hypertension, anxiety, dyspepsia, diabetes, prostatic hypertrophy, atrial fibrillation, COPD, cancer, stroke and ischemic heart disease; and among women hypertension, anxiety, joint degeneration, dyspepsia, diabetes, depression and osteoporosis. It was noted that more than half of the users had no of anxiety or depression, in addition, 72% did not have with self care. However, 61% of the users have moderate or severe in mobility, 56% in daily activities and 69% in the dimension of pain or discomfort. The mean of the overall rate of EQ VAS was higher among men and among older people

Conclusions II Parkinson, chronic heart disease (others), ischemic heart disease, rheumatoid arthritis and others, schizophrenia and hepatopancreatic chronic disease are those which reported the worst values in all dimensions of the Euroqol. The chronic diseases which obtained poorer EQ VAS global index were the Parkinson(0.46)andalcohol abuse (0.44). Distinguishing between sexes, for men were psoriasis or eczema (0.23)andrheumatoidarthritisandother (0.33)andforwomenwerealcohol abuse (0.32) and peripheral vascular disease (0.38). The study of the association between multimorbidity and quality of life showed that female gender, the number of chronic conditions and living with one or more persons got worse values in terms of HRQOL.

Conclusions III The study of the association between chronic diseases and each dimension of the EuroQol showed that: Joint degeneration and rheumatoid arthritis increased the risk of moderate or severe in the dimension of mobility, self care and pain or discomfort. Peripheral vascular disease increased the risk of having in the dimensions of daily activities, pain or discomfort and anxiety or depression. Heart failure increased the risk in the dimensions of mobility, daily activities and pain or discomfort. Parkinson or muscular dystrophy or paralysis increased the risk of having moderate or severe in self care, mobility and daily activities dimensions. Depression increased the risk of moderate or severe in the dimensions of self care, daily activities and obviously in anxiety or depression.

Future interventions We should identify most appropriate strategies for improving quality of life, especially in certain pathologies. Moreover, we should develop specific interventions in subgroups with similar characteristics (women or younger groups) to improve the quality of life and manage multimorbidity.

1. Alcohol 2. Anorexia or bulimia 3. Anxiety & other neurotic, stress related & somatoform disorders 4. Asthma (currently treated) 5. Atrial fibrillation 6. Attention deficit disorder 7. Blindness & low vision 8. Bronchiectasis 9. Cerebro vascular disease 10. Chromosomal anomalies or Inherited metabolic disorders 11. Chronic heart disease, others 12. Chronic kidney disease 13. Chronic liver or pancreatic disease 14. Chronic sinusitis 15. Deafness, hearing loss List of all chronic conditions 16. Degenerative joint disease 17. Dementia 18. Depression 19. Developmental disorder 20. Diabetes Mellitus 21. Disorders of the immune system 22. Diverticular disease of intestine 23. Emphysema, chronic bronchitis, COPD 24. Epilepsy (currently treated) 25. Glaucoma 26. Gout 27. Heart failure 28. Hematologic chronic disorders 29. HIV, AIDS 30. Hypertension 31. Hypothyroidism 32. Inflammatory bowel disease 33. Irritable bowel syndrome 34. Ischemic Heart Disease 35. Low back pain 36. Malignancies 37. Migraine 38. Multiple sclerosis 39. Osteoporosis 40. Other psycho active substance misuse 41. Paralysis or muscular dystrophy 42. Parkinson s disease 43. Peripheral neuropathy, neuritis 44. Peripheral vascular disease 45. Prostatic hypertrophy 46. Psoriasis or eczema 47. Rheumatoid arthritis and autoimmune and connective tissue diseases 48. Schizophrenia, affective psychosis or bipolar disorder 49. Transplant status 50. Treated constipation 51. Treated dyspepsia 52. Viral Hepatitis

Thank you very much Eskerrik asko Muchas gracias Mrs. Edurne Alonso Morán (edurne.almo@gmail.com). Biostatician Researcher. Collaborative Research of OSATEK, public company of Basque Government. Mrs. Lide Amilibia (l amilibia@ej gv.es). Social Services Director. Social Services Department of Basque Government. Mr. Enrique Gutiérrez (egutierrez@osatek.net). Managing Director. OSATEK, public company of Basque Government. Mr. Alfredo Alday (aalday@osatek.net) Telecare Area Manager. OSATEK, public company of Basque Government.

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