Trajectories of Chronic Disease and Multimorbidity Among Middle-aged and Older Patients at Community Health Centers.
Trajectories of Chronic Disease and Multimorbidity Among Middle-aged and Older Patients at Community Health Centers.
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社区卫生中心中老年患者的慢性病及共病发展轨迹
DOI：
10.1001/jamanetworkopen.2023.7497
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发表时间：
2023-04-03
影响因子：
13.8
通讯作者：
Marino, Miguel
中科院分区：
文献类型：
--
作者：
Quinones, Ana R.;Hwang, Jun;Heintzman, John;Huguet, Nathalie;Lucas, Jennifer A.;Schmidt, Teresa D.;Marino, Miguel
在社区卫生中心就诊的患者是否在中年早期就积累了慢性病，他们是否积累了复杂的慢性病模式？在这项纳入725107名患者的队列研究中，在安全网诊所寻求治疗的患者的慢性疾病水平较高且不断增加，疾病模式最常见的特征是心脏代谢疾病（特别是种族和少数民族群体中的成年人）和精神健康状况（特别是非西班牙裔白色成年人）。这项研究表明，在安全网诊所寻求治疗的患者在中年时患慢性病的比例很高，这表明需要更早和更好地预防慢性病。多发病（≥2种慢性疾病）的健康相关后果已有充分记录。然而，在安全网诊所寻求治疗的美国患者中慢性病积累的程度和速度并不清楚。需要这些见解，使临床医生，管理人员和政策制定者能够动员资源，预防这一人群的疾病升级。了解社区卫生服务中心中老年慢性病患者慢性病累积的模式和速率，以及社会人口统计学差异。这项队列研究使用了2012年1月1日至2019年12月31日的电子健康记录数据，涉及725107名45岁或以上的成年人，他们在美国26个州的国家社区卫生中心网络中的657家初级保健诊所在2年或更长时间内进行了2次或更多次门诊护理。于二零二一年九月至二零二三年二月进行统计分析。种族和民族、年龄、保险范围和联邦贫困水平（FPL）。病人一级的慢性病负担，可操作为多种慢性病框架建议的22种慢性病的总和。采用线性混合模型，对患者水平随机效应进行人口统计学特征和门诊访视频率与时间相互作用的调整，以比较人种和种族、年龄、收入和保险范围的增加。分析样本包括725107例患者（417067例女性[57.5%]; 359255例[49.5%]年龄为45-54岁，242571例[33.5%]年龄为55-64岁，123281例[17.0%]年龄≥65岁）。平均而言，在平均（SD）4.2（2.0）年的随访中，患者开始时的平均（SD）发病率为1.7（1.7），结束时的平均（SD）发病率为2.6（2.0）。与非西班牙裔白色患者相比，种族和民族少数群体患者的调整后疾病年累积率略低（偏好西班牙语的西班牙裔患者为−0.03 [95%CI，−0.03至−0.03];偏好英语的西班牙裔患者为−0.02 [95%CI，−0.02至−0.01];非西班牙裔黑人患者为−0.01 [95%CI，−0.01至−0.01];非西班牙裔亚裔患者为−0.04 [95%CI，−0.05至−0.04]）。与45至50岁的患者相比，老年患者的年发病率更高（50-55岁为0.03 [95% CI，0.02-0.03]，55-60岁为0.03 [95% CI，0.03-0.04]，60-65岁为0.04 [95% CI，0.04-0.04]; ≥65岁为0.05 [95% CI，0.05-0.05]）。与收入较高的患者（始终≥ FPL的138%）相比，收入低于FPL的138%（0.04 [95% CI，0.04-0.05]）、混合收入（0.01 [95% CI，0.01-0.01]）或收入水平未知（0.04 [95% CI，0.04-0.04]）的患者的年累积率较高。与连续投保的患者相比，连续未投保和不连续投保的患者的年累积率较低（连续未投保，-0.003 [95%CI，-0.005 to -0.001];不连续投保，-0.004 [95%CI，-0.005 to -0.003]）。这项对在社区卫生中心寻求治疗的中年患者的队列研究表明，患者的实际年龄的疾病发生率很高。需要针对接近或低于贫困线的患者开展慢性病预防工作。这项队列研究使用来自657个初级保健诊所的电子健康记录数据，以确定在社区卫生中心寻求护理的中老年患者中慢性病积累的模式和速度，以及任何社会人口统计学差异。
Do patients seen in community health centers accumulate chronic diseases early in midlife, and do they accumulate complex patterns of chronic disease? In this cohort study of 725 107 patients, those seeking care in safety-net clinics had high and increasing levels of chronic disease and patterns of disease most frequently characterized by cardiometabolic disease (particularly for adults in racial and ethnic minoritized groups) and mental health conditions (particularly for non-Hispanic White adults). This study suggests that patients seeking care in safety-net clinics are accruing chronic diseases at high rates in middle age, indicating a need for earlier and improved chronic disease prevention efforts. Health-related consequences of multimorbidity (≥2 chronic diseases) are well documented. However, the extent and rate of accumulation of chronic diseases among US patients seeking care in safety-net clinics are not well understood. These insights are needed to enable clinicians, administrators, and policy makers to mobilize resources for prevention of disease escalations in this population. To identify the patterns and rate of chronic disease accumulation among middle-aged and older patients seeking care in community health centers, as well as any sociodemographic differences. This cohort study used electronic health record data from January 1, 2012, to December 31, 2019, on 725 107 adults aged 45 years or older with 2 or more ambulatory care visits in 2 or more distinct years at 657 primary care clinics in the Advancing Data Value Across a National Community Health Center network in 26 US states. Statistical analysis was performed from September 2021 to February 2023. Race and ethnicity, age, insurance coverage, and federal poverty level (FPL). Patient-level chronic disease burden, operationalized as the sum of 22 chronic diseases recommended by the Multiple Chronic Conditions Framework. Linear mixed models with patient-level random effects adjusted for demographic characteristics and ambulatory visit frequency with time interactions were estimated to compare accrual by race and ethnicity, age, income, and insurance coverage. The analytic sample included 725 107 patients (417 067 women [57.5%]; 359 255 [49.5%] aged 45-54 years, 242 571 [33.5%] aged 55-64 years, and 123 281 [17.0%] aged ≥65 years). On average, patients started with a mean (SD) of 1.7 (1.7) morbidities and ended with 2.6 (2.0) morbidities over a mean (SD) of 4.2 (2.0) years of follow-up. Compared with non-Hispanic White patients, patients in racial and ethnic minoritized groups had marginally lower adjusted annual rates of accrual of conditions (−0.03 [95% CI, −0.03 to −0.03] for Spanish-preferring Hispanic patients; −0.02 [95% CI, −0.02 to −0.01] for English-preferring Hispanic patients; −0.01 [95% CI, −0.01 to −0.01] for non-Hispanic Black patients; and −0.04 [95% CI, −0.05 to −0.04] for non-Hispanic Asian patients). Older patients accrued conditions at higher annual rates compared with patients 45 to 50 years of age (0.03 [95% CI, 0.02-0.03] for 50-55 years; 0.03 [95% CI, 0.03-0.04] for 55-60 years; 0.04 [95% CI, 0.04-0.04] for 60-65 years; and 0.05 [95% CI, 0.05-0.05] for ≥65 years). Compared with those with higher income (always ≥138% of the FPL), patients with income less than 138% of the FPL (0.04 [95% CI, 0.04-0.05]), mixed income (0.01 [95% CI, 0.01-0.01]), or unknown income levels (0.04 [95% CI, 0.04-0.04]) had higher annual accrual rates. Compared with continuously insured patients, continuously uninsured and discontinuously insured patients had lower annual accrual rates (continuously uninsured, −0.003 [95% CI, –0.005 to –0.001]; discontinuously insured, −0.004 [95% CI, –0.005 to –0.003]). This cohort study of middle-aged patients seeking care in community health centers suggests that disease accrued at high rates for patients’ chronological age. Targeted efforts for chronic disease prevention are needed for patients near or below the poverty line. This cohort study uses electronic health record data from 657 primary care clinics to identify the patterns and rate of chronic disease accumulation among middle-aged and older patients seeking care in community health centers, as well as any sociodemographic differences.
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DOI：
10.1097/phm.0000000000001388
发表时间：
2020-05-01
影响因子：
3
作者：
Jacob, Mini E.;Ni, Pengsheng;Bean, Jonathan F.
通讯作者：
Bean, Jonathan F.
DOI：
10.3122/jabfm.2009.02.080035
发表时间：
2009-03
期刊：
Journal of the American Board of Family Medicine : JABFM
影响因子：
--
作者：
Ani C;Bazargan M;Hindman D;Bell D;Rodriguez M;Baker RS
通讯作者：
Baker RS
影响因子：
3.7
作者：
Oanh Kieu Nguyen;Makam, Anil N.;Halm, Ethan A.
通讯作者：
Halm, Ethan A.
DOI：
10.3122/jabfm.2019.06.190087
发表时间：
2019-11-01
影响因子：
2.9
作者：
Huguet, Nathalie;Angier, Heather;DeVoe, Jennifer E.
通讯作者：
DeVoe, Jennifer E.
影响因子：
2.9
作者：
Ashworth, Mark;Durbaba, Stevo;Dodhia, Hiten
通讯作者：
Dodhia, Hiten