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BMC Medicine
Published in: BMC Medicine 1/2023

Open Access 01-12-2023 | Care | Research article

Healthcare fragmentation, multimorbidity, potentially inappropriate medication, and mortality: a Danish nationwide cohort study

Authors: Anders Prior, Claus Høstrup Vestergaard, Peter Vedsted, Susan M. Smith, Line Flytkjær Virgilsen, Linda Aagaard Rasmussen, Morten Fenger-Grøn

Published in: BMC Medicine | Issue 1/2023

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Abstract

Background

Patients with multimorbidity are frequent users of healthcare, but fragmented care may lead to suboptimal treatment. Yet, this has never been examined across healthcare sectors on a national scale. We aimed to quantify care fragmentation using various measures and to analyze the associations with patient outcomes.

Methods

We conducted a register-based nationwide cohort study with 4.7 million Danish adult citizens. All healthcare contacts to primary care and hospitals during 2018 were recorded. Clinical fragmentation indicators included number of healthcare contacts, involved providers, provider transitions, and hospital trajectories. Formal fragmentation indices assessed care concentration, dispersion, and contact sequence. The patient outcomes were potentially inappropriate medication and all-cause mortality adjusted for demographics, socioeconomic factors, and morbidity level.

Results

The number of involved healthcare providers, provider transitions, and hospital trajectories rose with increasing morbidity levels. Patients with 3 versus 6 conditions had a mean of 4.0 versus 6.9 involved providers and 6.6 versus 13.7 provider transitions. The proportion of contacts to the patient’s own general practice remained stable across morbidity levels. High levels of care fragmentation were associated with higher rates of potentially inappropriate medication and increased mortality on all fragmentation measures after adjusting for demographic characteristics, socioeconomic factors, and morbidity. The strongest associations with potentially inappropriate medication and mortality were found for ≥ 20 contacts versus none (incidence rate ratio 2.83, 95% CI 2.77–2.90) and ≥ 20 hospital trajectories versus none (hazard ratio 10.8, 95% CI 9.48–12.4), respectively. Having less than 25% of contacts with your usual provider was associated with an incidence rate ratio of potentially inappropriate medication of 1.49 (95% CI 1.40–1.58) and a mortality hazard ratio of 2.59 (95% CI 2.36–2.84) compared with full continuity. For the associations between fragmentation measures and patient outcomes, there were no clear interactions with number of conditions.

Conclusions

Several clinical indicators of care fragmentation were associated with morbidity level. Care fragmentation was associated with higher rates of potentially inappropriate medication and increased mortality even when adjusting for the most important confounders. Frequent contact to the usual provider, fewer transitions, and better coordination were associated with better patient outcomes regardless of morbidity level.
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Literature
1.
Bell C, Prior A, Frølich A, Appel CW, Vedsted P. Trajectories in outpatient care for people with multimorbidity: a population-based register study in Denmark. Clin Epidemiol. 2022;14:749–62.PubMedPubMedCentral
2.
Frølich A, Ghith N, Schiøtz M, Jacobsen R, Stockmarr A. Multimorbidity, healthcare utilization and socioeconomic status: a Register-based study in Denmark. PLoS ONE. 2019;14(8):e0214183–e0214183.PubMedPubMedCentral
3.
Prior A, Vestergaard CH, Ribe AR, Sandbæk A, Bro F, Vedsted P, Smith S, Vestergaard M, Fenger-Grøn M. Chronic care services and variation between Danish general practices: a nationwide cohort study. Br J Gen Pract. 2021;72(717):e285–92.
4.
Prior A, Fenger-Grøn M, Larsen KK, Larsen FB, Robinson KM, Nielsen MG, Christensen KS, Mercer SW, Vestergaard M. The association between perceived stress and mortality among people with multimorbidity: a prospective population-based cohort study. Am J Epidemiol. 2016;184(3):199–210.PubMed
5.
Larsen FB, Pedersen MH, Friis K, Glümer C, Lasgaard M. A latent class analysis of multimorbidity and the relationship to socio-demographic factors and health-related quality of life. a national population-based study of 162,283 Danish adults. PLoS One. 2017;12(1):e0169426–e0169426.PubMedPubMedCentral
6.
Prior A, Vestergaard M, Davydow DS, Larsen KK, Ribe AR, Fenger-Grøn M. Perceived stress, multimorbidity, and risk for hospitalizations for ambulatory care-sensitive conditions: a population-based cohort study. Med Care. 2017;55(2):131–9.PubMed
7.
Lund Jensen N, Pedersen HS, Vestergaard M, Mercer SW, Glümer C, Prior A. The impact of socioeconomic status and multimorbidity on mortality: a population-based cohort study. Clin Epidemiol. 2017;9:279–89.PubMedPubMedCentral
8.
Wallace E, Salisbury C, Guthrie B, Lewis C, Fahey T, Smith SM. Managing patients with multimorbidity in primary care. BMJ. 2015;350(jan20 2):h176–h176.PubMed
9.
10.
Pereira Gray DJ, Sidaway-Lee K, White E, Thorne A, Evans PH. Continuity of care with doctors-a matter of life and death? A systematic review of continuity of care and mortality. BMJ Open. 2018;8(6):e021161–e021161.PubMedPubMedCentral
11.
Baker R, Bankart MJ, Freeman GK, Haggerty JL, Nockels KH. Primary medical care continuity and patient mortality. Br J Gen Pract. 2020;70(698):E600–11.PubMedPubMedCentral
12.
Sandvik H, Hetlevik Ø, Blinkenberg J, Hunskaar S. Continuity in general practice as predictor of mortality, acute hospitalisation, and use of out-of-hours care: a registry-based observational study in Norway. Br J Gen Pract. 2021;72(715):e84–90.PubMedCentral
13.
Wang C, Kuo HC, Cheng SF, Hung JL, Xiong JH, Tang PL. Continuity of care and multiple chronic conditions impact frequent use of outpatient services. Health Informatics J. 2020;26(1):318–27.PubMed
14.
Barker I, Steventon A, Deeny SR. Association between continuity of care in general practice and hospital admissions for ambulatory care sensitive conditions: cross sectional study of routinely collected, person level data. BMJ. 2017;356:j84–j84.PubMed
15.
Kao Y-H, Lin W-T, Chen W-H, Wu S-C, Tseng T-S. Continuity of outpatient care and avoidable hospitalization: a systematic review. Am J Manag Care. 2019;25(4):e126–34.PubMed
16.
Bayliss EA, Ellis JL, Shoup JA, Zeng C, McQuillan DB, Steiner JF. Effect of continuity of care on hospital utilization for seniors with multiple medical conditions in an integrated health care system. Ann Fam Med. 2015;13(2):123–9.PubMedPubMedCentral
17.
Chu HY, Chen CC, Cheng SH. Continuity of care, potentially inappropriate medication, and health care outcomes among the elderly: evidence from a longitudinal analysis in Taiwan. Med Care. 2012;50(11):1002–9.PubMed
18.
Sinnott C, Mc Hugh S, Browne J, Bradley C. GPs’ perspectives on the management of patients with multimorbidity: systematic review and synthesis of qualitative research. BMJ Open. 2013;3(9):e003610–e003610.PubMedPubMedCentral
19.
Bayliss EA, Edwards AE, Steiner JF, Main DS. Processes of care desired by elderly patients with multimorbidities. Family Pract. 2008;25:287–93.
20.
Adeniji C, Kenning C, Coventry PA, Bower P. What are the core predictors of ‘hassles’ among patients with multimorbidity in primary care? A cross sectional study. BMC Health Serv Res. 2015;15:255–255.PubMedPubMedCentral
21.
Muth C, van den Akker M, Blom JW, Mallen CD, Rochon J, Schellevis FG, Becker A, Beyer M, Gensichen J, Kirchner H, et al. The Ariadne principles: how to handle multimorbidity in primary care consultations. BMC Med. 2014;12:223–223.PubMedPubMedCentral
22.
Moth G, Vestergaard M, Vedsted P. Chronic care management in Danish general practice - a cross–sectional study of workload and multimorbidity. BMC Fam Pract. 2012;13(1):52–52.PubMedPubMedCentral
23.
Ørtenblad L, Meillier L, Jønsson AR. Multi-morbidity: a patient perspective on navigating the health care system and everyday life. Health Expect. 2015;18(3):312–24.
24.
Sav A, King MA, Whitty JA, Kendall E, McMillan SS, Kelly F, Hunter B, Wheeler AJ. Burden of treatment for chronic illness: a concept analysis and review of the literature. Health Expect. 2015;18(3):312–24.PubMed
25.
26.
27.
Guthrie B, Saultz JW, Freeman GK, Haggerty JL. Continuity of care matters. BMJ. 2008;337(7669):548–9.
28.
Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet. 2012;380(9836):37–43.PubMed
29.
Mercer SW, Gunn J, Bower P, Wyke S, Guthrie B. Managing patients with mental and physical multimorbidity. BMJ. 2012;345(sep03 1):e5559–e5559.PubMed
30.
Pollack CE, Hussey PS, Rudin RS, Fox DS, Lai J, Schneider EC. Measuring care continuity: a comparison of claims-based methods. Med Care. 2016;54(5):e30-34.PubMedPubMedCentral
31.
Erlangsen A, Fedyszyn I. Danish nationwide registers for public health and health-related research. Scand J Public Health. 2015;43(4):333–9.PubMed
32.
Christiansen T. Organization and financing of the Danish health care system. Health Policy. 2002;59(2):107–18.PubMed
33.
Pedersen KM, Andersen JS, Søndergaard J. General practice and primary health care in Denmark. J Am Board Fam Med. 2012;25(Suppl 1):S34-38.PubMed
34.
Pedersen CB, Gøtzsche H, Møller JO, Mortensen PB. The Danish civil registration system. A cohort of eight million persons. Dan Med Bull. 2006;53(4):441–9.PubMed
35.
Pottegård A, Schmidt SAJ, Wallach-Kildemoes H, Sørensen HT, Hallas J, Schmidt M. Data resource profile: the Danish national prescription registry. Int J Epidemiol. 2016;25(3):dyw213–dyw213.
36.
Andersen JS, Olivarius NDF, Krasnik A. The Danish national health service register. Scand J Public Health. 2011;39(7 Suppl):34–7.PubMed
37.
Lynge E, Sandegaard JL, Rebolj M. The Danish national patient register. Scand J Public Health. 2011;39(7 Suppl):30–3.PubMed
38.
Jee SH, Cabana MD. Indices for continuity of care: a systematic review of the literature. Med Care Res Rev. 2006;63(2):158–88.PubMed
39.
Salisbury C, Sampson F, Ridd M, Montgomery AA. How should continuity of care in primary health care be assessed? Br J Gen Pract. 2009;59(561):e134–41.PubMedPubMedCentral
40.
Given CW, Branson M, Zemach R. Evaluation and application of continuity measures in primary care settings. J Community Health. 1985;10(1):22–41.PubMed
41.
Hull SA, Williams C, Schofield P, Boomla K, Ashworth M. Measuring continuity of care in general practice: a comparison of two methods using routinely collected data. Br J Gen Pract. 2022;72(724):e773–9.PubMedPubMedCentral
42.
Bice TW, Boxerman SB. A quantitative measure of continuity of care. Med Care. 1977;15(4):347–9.PubMed
43.
Rosenberg NA, Zulman DM. Measures of care fragmentation: mathematical insights from population genetics. Health Serv Res. 2020;55(2):318–27.PubMedPubMedCentral
44.
Cahir C, Bennett K, Teljeur C, Fahey T. Potentially inappropriate prescribing and adverse health outcomes in community dwelling older patients. Br J Clin Pharmacol. 2014;77(1):201–10.PubMed
45.
O’Mahony D, O’Sullivan D, Byrne S, O’Connor MN, Ryan C, Gallagher P. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing. 2015;44(2):213–8.PubMed
46.
Ribe AR, Christensen LD, Vestergaard CH, Prior A, Brynningsen PK, Bro F, Sandbæk A, Vedsted P, Witte DR, Fenger-Grøn M. Potentially inappropriate medications (PIMs): frequency and extent of GP-related variation in PIMs: a register-based cohort study. BMJ Open. 2021;11(7):e046756–e046756.PubMedPubMedCentral
47.
Kohnke H, Zielinski A. Association between continuity of care in Swedish primary care and emergency services utilisation: a population-based cross-sectional study. Scand J Prim Health Care. 2017;35(2):113–9.PubMedPubMedCentral
48.
Saultz JW, Albedaiwi W. Interpersonal continuity of care and patient satisfaction: a critical review. Ann Fam Med. 2004;2(5):445–51.PubMedPubMedCentral
49.
Freeman GK, Olesen F, Hjortdahl P. Continuity of care: an essential element of modern general practice? Fam Pract. 2003;20(6):623–7.PubMed
50.
Skou ST, Mair FS, Fortin M, Guthrie B, Nunes BP, Miranda JJ, Boyd CM, Pati S, Mtenga S, Smith SM. Multimorbidity. Nat Rev Dis Primers. 2022;8(1):48.PubMedPubMedCentral
51.
Smith SM, Wallace E, Clyne B, Boland F, Fortin M. Interventions for improving outcomes in patients with multimorbidity in primary care and community setting: a systematic review. Syst Rev. 2021;10(1):271.PubMedPubMedCentral
52.
Salisbury C, Man MS, Bower P, Guthrie B, Chaplin K, Gaunt DM, Brookes S, Fitzpatrick B, Gardner C, Hollinghurst S, et al. Management of multimorbidity using a patient-centred care model: a pragmatic cluster-randomised trial of the 3D approach. Lancet. 2018;392(10141):41–50.PubMedPubMedCentral
53.
Bell C, Appel CW, Frolich A, Prior A, Vedsted P. Improving health care for patients with multimorbidity: a mixed-methods study to explore the feasibility and process of aligning scheduled outpatient appointments through collaboration between medical specialties. Int J Integr Care. 2022;22(1):17.PubMedPubMedCentral
Metadata
Title
Healthcare fragmentation, multimorbidity, potentially inappropriate medication, and mortality: a Danish nationwide cohort study
Authors
Anders Prior
Claus Høstrup Vestergaard
Peter Vedsted
Susan M. Smith
Line Flytkjær Virgilsen
Linda Aagaard Rasmussen
Morten Fenger-Grøn
Publication date
01-12-2023
Publisher
BioMed Central
Keyword
Care
Published in
BMC Medicine / Issue 1/2023
Electronic ISSN: 1741-7015
DOI
https://doi.org/10.1186/s12916-023-03021-3

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