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Association of Multimorbidity with Mortality and Healthcare Utilization in Chronic Kidney Disease
C Barrett Bowling1,2, Laura Plantinga2, Lawrence S Phillips2,3
1Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Atlanta VA Medical Center, Decatur, Georgia.
Insights
Chronic kidney disease (CKD) patients with discordant or unrelated conditions face higher mortality and hospitalization risks. This highlights the complex impact of multimorbidity beyond simple condition counts.
Area of Science:
- Nephrology
- Geriatrics
- Public Health
Background:
- Chronic kidney disease (CKD) frequently co-occurs with other medical conditions (multimorbidity).
- Existing frameworks for multimorbidity often do not differentiate conditions based on treatment goal alignment.
- Classifying comorbidities as concordant, discordant, or unrelated is crucial for understanding complex patient needs.
Purpose of the Study:
- To analyze the impact of CKD-related multimorbidity using a framework of concordant, discordant, and unrelated conditions.
- To investigate the association between the number of chronic conditions, stratified by discordance, and adverse health outcomes.
- To determine the independent effect of discordant/unrelated conditions on mortality, hospitalizations, and emergency department visits in CKD patients.
Main Methods:
- Retrospective cohort study of 821,334 Veterans Affairs patients with incident CKD.
- Analysis included stratifying patients by the number of chronic conditions and the presence of discordant/unrelated conditions.
- Outcomes assessed included mortality, hospitalizations, and emergency department visits over a median follow-up of 6.8 years.
Main Results:
- Higher numbers of chronic conditions correlated with increased risks of death, hospitalization, and ED visits.
- The presence of at least one discordant or unrelated condition significantly amplified these risks compared to concordant conditions alone.
- Patients with six or more conditions, including at least one discordant/unrelated condition, showed a substantially higher mortality hazard ratio (2.05) than those with only concordant conditions (1.72).
Conclusions:
- Discordant and unrelated chronic conditions exacerbate the adverse health outcomes associated with multimorbidity in CKD patients.
- The complexity of managing co-existing conditions with conflicting or disparate treatment goals significantly impacts patient prognosis.
- This framework provides a more nuanced understanding of multimorbidity, essential for optimizing care strategies in CKD.
Objectives:
Chronic kidney disease (CKD) almost universally occurs in individuals with other medical problems. However, few studies have described CKD-related multimorbidity using a framework that identifies chronic conditions as concordant (having overlap in treatment goals) versus discordant (having opposing treatment recommendations) and unrelated (having no overlap, but contributing to complexity via different resource requirements).
Design:
Retrospective cohort.
Setting:
Veterans Affairs (VA) Medical Centers.
Participants:
VA patients (n = 821,334) ages 18-100 years with at least one outpatient visit and incident CKD defined as an estimated glomerular filtration rate <60 mL/min/1.73 m2 for at least 3 months between January 1, 2005 and December 31, 2008 after excluding prevalent CKD.
Measurements:
We determined the associations of number of chronic conditions (1, 2, 3, 4, 5, 6 or more) stratified by the presence of one or more discordant/unrelated conditions with mortality, hospitalizations and emergency department (ED) visits.
Results:
There were 381,187 deaths over 6.8 median years of follow-up. Higher risks of death, hospitalization and ED visits were associated with higher number of chronic conditions, among those with and without discordant/unrelated conditions. However, the magnitudes of the associations were consistently larger when at least one discordant/unrelated condition was present. For example, compared to patients with one concordant condition, patients with six or more concordant conditions had an age-, race- and sex-adjusted hazard ratio (HR) for mortality of 1.72 (95% CI 1.64-1.80) whereas those with six or more conditions, at least one of which was discordant/unrelated, had a HR of 2.05 (2.01-2.09) (P-interaction <0.001).
Conclusions:
The presence of one or more discordant/unrelated conditions was associated with increased risk for adverse health outcomes, beyond the effect of multimorbidity.
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