Descriptive analyses
Analyses included 843 patients from 28 to 98 years old, with a mean age of 73.0 (SD 12.0), 48.3% of whom were men. Their characteristics are reported in Table 1. The most frequent chronic conditions were hypertension, cardiovascular disease risk factors, diabetes, obesity, and ischemic heart disease, but 74/75 chronic conditions of the list were mentioned at least once.
Table 1.
Socio-demographic and other characteristics of the multimorbid patient sample, N = 843
|
All
|
Women
|
Men
|
p-value
|
|
|
Participants
|
|
|
|
|
|
N (%)
|
843 (100)
|
436 (51.7)
|
407 (48.3)
|
-
|
|
Age
|
|
|
|
|
|
Mean (SD)
|
73.0 (12.0)
|
72.9 (13.4)
|
73.1 (10.3)
|
0.848
|
|
Range (years)
|
28–98
|
28–97
|
33–98
|
|
|
< 65 years, n (%)
|
187 (22.2)
|
107 (24.5)
|
80 (19.7)
|
0.002
|
|
65–74 years, n (%)
|
240 (28.5)
|
104 (23.8)
|
136 (33.4)
|
-
|
|
75–84 years, n (%)
|
278 (33.0)
|
140 (32.1)
|
138 (33.9)
|
-
|
|
≥ 85 years, n (%)
|
138 (16.4)
|
85 (19.5)
|
53 (13.0)
|
-
|
|
Marital status+
|
|
|
|
|
|
Single, n (%)
|
80 (9.5)
|
50 (11.5)
|
30 (7.4)
|
< 0.001
|
|
Married, n (%)
|
418 (49.6)
|
155 (35.5)
|
263 (64.6)
|
-
|
|
Separated/Divorced, n (%)
|
143 (17.0)
|
75 (17.2)
|
68 (16.7)
|
-
|
|
Widowed, n (%)
|
202 (24.0)
|
156 (35.8)
|
46 (11.3)
|
-
|
|
|
|
|
|
|
Mean number of adults in household+ (SD)
|
1.7 (0.6)
|
1.5 (0.6)
|
1.8 (0.6)
|
< 0.001
|
|
Presence of an informal caregiver+, n (%)
|
572 (67.8)
|
292 (67.0)
|
280 (68.8)
|
0.571
|
|
Educational level+
|
|
|
|
|
Primary, n (%)
|
186 (22.1)
|
124 (28.4)
|
62 (15.2)
|
< 0.001
|
|
Secondary, n (%)
|
319 (37.8)
|
181 (41.5)
|
138 (33.9)
|
-
|
|
Tertiary, n (%)
|
338 (40.1)
|
131 (30.0)
|
207 (50.9)
|
-
|
|
Linguistic region
|
|
|
|
|
French-speaking, n (%)
|
325 (38.5)
|
173 (39.7)
|
152 (37.3)
|
0.487
|
|
German-speaking, n (%)
|
518 (61.4)
|
263 (60.3)
|
255 (62.6)
|
-
|
|
Location of GP's practice
|
|
|
|
|
Urban, n (%)
|
367 (43.5)
|
204 (46.8)
|
163 (40.0)
|
0.129
|
|
Semi-urban, n (%)
|
339 (40.2)
|
163 (37.4)
|
176 (43.2)
|
-
|
|
Rural, n (%)
|
137 (16.3)
|
69 (15.8)
|
68 (16.7)
|
-
|
|
|
|
|
|
|
|
Mean number of chronic conditions (SD)
|
5.4 (2.2)
|
5.4 (2.1)
|
5.5 (2.2)
|
0.519
|
|
Mean number of medications (SD)
|
7.7 (3.5)
|
7.9 (3.6)
|
7.5 (3.3)
|
0.067
|
|
Mean CIRS score* (SD)
|
10.2 (4.3)
|
10.0 (4.3)
|
10.5 (4.3)
|
0.068
|
|
Mean treatment burden (evaluated by GP; SD)
|
4.5 (1.7)
|
4.6 (1.7)
|
4.4 (1.7)
|
0.109
|
|
Mean TBQ score** + (SD)
|
26.8 (18.8)
|
26.6 (18.6)
|
26.9 (19.0)
|
0.850
|
|
DipCare Index
|
|
|
|
|
|
Mean material deprivation score (SD)
|
0.5 (1.3)
|
0.6 (1.4)
|
0.4 (1.1)
|
0.014
|
|
Mean social deprivation score (SD)
|
3.1 (1.4)
|
3.0 (1.4)
|
3.1 (1.4)
|
0.119
|
|
Mean healthcare deprivation score (SD)
|
0.5 (0.7)
|
0.5 (0.7)
|
0.4 (0.7)
|
0.034
|
|
Quality of life (EQ-5D-3L)+
|
|
|
|
|
|
Mobility
|
Problematic, n (%)
|
372 (44.1)
|
210 (48.2)
|
162 (39.8)
|
0.015
|
|
Self-care
|
Problematic, n (%)
|
98 (11.6)
|
53 (12.2)
|
45 (11.1)
|
0.619
|
|
Usual activities
|
Problematic, n (%)
|
327 (38.8)
|
198 (45.4)
|
129 (31.7)
|
< 0.001
|
|
Pain/Discomfort
|
Problematic, n (%)
|
643 (76.3)
|
356 (81.6)
|
287 (70.5)
|
< 0.001
|
|
Anxiety/Depression
|
Problematic, n (%)
|
355 (42.1)
|
228 (52.3)
|
127 (31.2)
|
< 0.001
|
|
Visual Analog Scale (VAS), Mean (SD)
|
63.1 (19.4)
|
60.4 (19.4)
|
65.9 (19.0)
|
< 0.001
|
|
Results are expressed as the number of participants (percentage) or as an average ± standard deviation. p-values express differences between men and women.
*CIRS = Cumulative illness rating scale. **TBQ = Treatment burden questionnaire. +Self-perceived
Details of the bivariate analyses involving the four dependent outcome variables (use of homecare services, use of other allied health services, number of contacts with GPs, and number of specialists involved) and the comparisons between the users and non-users of homecare and other allied health services can be found in the Supplementary Material (Additional File 1). Analyses of the intermediate Andersen models considering predisposing factors alone (Model 1) and predisposing and enabling factors together (Model 2) are in the Additional File 2.
Results from the multivariate analyses of the complete Andersen model (Model 3), integrating the predisposing, enabling, and need factors for our four outcomes are shown in Table 2. The final models revealed that the four outcomes were not equally associated with either the factors or the categories. Although the use of homecare services and the number of specialists consulted were associated with factors from all three categories (predisposing, enabling, and need), GP–patient contacts were associated with predisposing and need factors, and the use of other allied health services was only associated with need factors.
Homecare services
Homecare services were used by 15.1% (127/843) of the patient sample and use increased with age (>85 years vs. <65 years, OR 4.22, 95%CI 1.62–10.99). In the complete model, using a higher number of medications (OR 1.13, 95%CI 1.05-1.21) and being less independent (OR 2.47, 95%CI 1.36–4.51) were associated with the use of homecare services. It was noteworthy that social deprivation (OR 0.75, 95%CI 0.62–0.89) and the absence of an informal caregiver (OR 0.5, 95%CI 0.28–0.88) were, however, related to a lower homecare services use.
Other allied health services
Other allied healthcare services (e.g., physiotherapy or occupational therapy) had been used by 34.9% (294/843) of patients during the preceding year. After adjusting for all factors (Model 3), only reporting pain or discomfort in the EQ-5D-3L questionnaire (OR 2.49, 95%CI 1.59–3.90) remained associated with the use of other allied health services.
Contact with GPs
In the preceding 12 months, participants had a median of 11 contacts with their GP (IQR 7–16). Multivariate analysis showed that the predisposing factors of age (>85 years vs. <65 years, IRR 1.26, 95%CI 1.08–1.46) and the absence of an informal caregiver (IRR 0.90, 95%CI 0.83–0.98) were associated with the number of GP–patient contacts. Among need factors, higher numbers of medications (IRR 1.03, 95%CI 1.02–1.04), a higher cumulative illness rating scale CIRS (IRR 1.01, 95%CI 1.00–1.03), a higher treatment burden (IRR 1.08, 95%CI 1.05–1.10) (as evaluated by the GP), and problems performing usual activities of daily life (IRR 1.09, 95%CI 1.00–1.20) were associated with more GP–patient contacts.
Number of specialists involved
Most patients, 84% (708/843), had consulted one or more specialists in the preceding 12 months, with a mean (SD) of 1.9 (1.4) specialists seen. There was no clear association between the number of specialists seen and age. The 75–84 years old age group was associated with a higher number of specialists consulted than those <65 years old (IRR 1.19, 95%CI 1.01–1.41), but not than the oldest old (>85 years, IRR 0.96, 95%CI 0.77–1.20). The fully adjusted model confirmed associations between a greater number of specialists consulted and certain predisposing factors, such as a higher educational level (tertiary education level, IRR 1.21, 95%CI 1.05–1.40) and linguistic region (higher in the French than the German-speaking region, IRR 1.23, 95%CI 1.10–1.37), and certain enabling factors, such as social deprivation (IRR 1.07, 95%CI 1.03–1.12). Need factors such as the number of chronic conditions (IRR 1.02, 95%CI 1.00–1.05), the number of medications prescribed (IRR 1.04, 95%CI 1.02–1.06), and the treatment burden (IRR 1.06, 95% 1.02–1.10) were also associated with the number of specialists consulted.
Table 2.
Multivariate analysis of factors associated with the outcome variables of ambulatory healthcare services use (homecare, allied health services, number of GP–patient contacts and number of specialists consulted), considering Andersen's model, controlled for predisposing factors + enabling factors + need factors; N = 843
|
Homecare services
|
Allied health services
|
Contacts with GP in last 12 months
|
Number of specialists
|
|
|
Odds ratio (95% CI)
|
Odds ratio (95% CI)
|
IRR (95% CI)
|
IRR (95% CI)
|
Predisposing factors
|
|
|
|
|
|
Sex
|
Men
|
1 (ref.)
|
1 (ref.)
|
1 (ref.)
|
1 (ref.)
|
|
|
Women
|
1.48 (0.88–2.49)
|
1.24 (0.91–1.69)
|
1.00 (0.92–1.08)
|
0.93 (0.84–1.04)
|
|
Age
|
< 65 years
|
1 (ref.)
|
1 (ref.)
|
1 (ref.)
|
1 (ref.)
|
|
|
65–74 years
|
1.03 (0.43–2.50)
|
1.11 (0.69–1.77)
|
1.11 (0.99–1.25)
|
1.17 (1.00–1.37)
|
|
|
75–84 years
|
1.82 (0.77–4.29)
|
0.78 (0.48–1.27)
|
1.21 (1.07–1.36)
|
1.19 (1.01–1.41)
|
|
|
85+ years
|
4.22 (1.62–10.99)
|
0.87 (0.49–1.53)
|
1.26 (1.08–1.46)
|
0.96 (0.77–1.20)
|
|
Marital status
|
Single
|
1 (ref.)
|
-
|
1 (ref.)
|
1 (ref.)
|
|
Married
|
1.10 (0.38–3.18)
|
-
|
1.57 (1.35–1.82)
|
0.95 (0.77–1.17)
|
|
Separated/Divorced
|
2.02 (0.88–4.65)
|
-
|
1.12 (0.99–1.26)
|
1.03 (0.87–1.21)
|
|
Widowed
|
1.60 (0.73–3.54)
|
-
|
1.08 (0.95–1.23)
|
0.88 (0.74–1.05)
|
|
Number of adults in household
|
0.69 (0.38–1.25)
|
-
|
1.04 (0.96–1.12)
|
1.08 (0.97–1.20)
|
|
Presence of an informal caregiver
|
Presence
|
1 (ref.)
|
-
|
1 (ref.)
|
-
|
|
Absence
|
0.50 (0.28–0.88)
|
-
|
0.90 (0.83–0.98)
|
-
|
|
Educational level
|
Primary
|
-
|
-
|
1 (ref.)
|
1 (ref.)
|
|
Secondary
|
-
|
-
|
0.94 (0.85–1.04)
|
1.07 (0.93–1.24)
|
|
Tertiary
|
-
|
-
|
0.86 (0.78–0.96)
|
1.21 (1.05–1.40)
|
|
Linguistic region
|
German-speaking
|
-
|
1 (ref.)
|
1 (ref.)
|
1 (ref.)
|
|
French-speaking
|
-
|
0.80 (0.58–1.11)
|
0.80 (0.73–0.86)
|
1.23 (1.10–1.37)
|
|
Location of GP's practice
|
Urban
|
-
|
-
|
-
|
1 (ref.)
|
|
Semi-urban
|
-
|
-
|
-
|
0.88 (0.79–0.98)
|
|
Rural
|
-
|
-
|
-
|
0.83 (0.72–0.97)
|
Enabling factors
|
|
|
|
|
|
Material deprivation
|
0.85 (0.67–1.06)
|
1.07 (0.94–1.23)
|
-
|
1.00 (0.96–1.05)
|
|
Social deprivation
|
0.75 (0.62–0.89)
|
-
|
1.01 (0.98–1.04)
|
1.07 (1.03–1.12)
|
|
Healthcare deprivation
|
1.06 (0.70–1.61)
|
1.20 (0.91–1.57)
|
1.00 (0.93–1.07)
|
1.02 (0.93–1.11)
|
Need factors
|
|
|
|
|
|
Number of chronic conditions
|
1.04 (0.93–1.16)
|
1.06 (0.98–1.15)
|
0.99 (0.97–1.01)
|
1.02 (1.00–1.05)
|
|
Number of medications
|
1.13 (1.05–1.21)
|
1.01 (0.96–1.06)
|
1.03 (1.02–1.04)
|
1.04 (1.02–1.06)
|
|
CIRS score°
|
1.00 (0.94–1.07)
|
1.01 (0.97–1.06)
|
1.01 (1.00–1.03)
|
1.01 (1.00–1.03)
|
|
Treatment burden
|
1.15 (0.98–1.33)
|
1.10 (0.99–1.22)
|
1.08 (1.05–1.10)
|
1.06 (1.02–1.10)
|
|
TBQ score°°
|
1.00 (0.99–1.01)
|
1.00 (0.99–1.01)
|
1.00 (1.00–1.00)
|
1.00 (1.00–1.00)
|
|
Perceived health state(EQ-5D-3L)
|
Mobility
|
Non-problematic
|
1 (ref.)
|
1 (ref.)
|
1 (ref.)
|
1 (ref.)
|
|
Problematic
|
1.26 (0.74–2.14)
|
1.27 (0.90–1.80)
|
0.99 (0.91–1.08)
|
1.01 (0.90–1.13)
|
|
Self-care
|
Non-problematic
|
1 (ref.)
|
1 (ref.)
|
1 (ref.)
|
1 (ref.)
|
|
Problematic
|
2.47 (1.36–4.51)
|
0.86 (0.52–1.42)
|
0.87 (0.77–0.99)
|
0.95 (0.80–1.12)
|
|
Usual activities
|
Non-problematic
|
1(ref.)
|
1(ref.)
|
1(ref.)
|
1(ref.)
|
|
Problematic
|
1.45 (0.84–2.49)
|
1.35 (0.93–1.94)
|
1.09 (1.00–1.20)
|
1.05 (0.92–1.18)
|
|
Pain/Discomfort
|
Non-problematic
|
1 (ref.)
|
1 (ref.)
|
-
|
1 (ref.)
|
|
Problematic
|
0.86 (0.45–1.66)
|
2.49 (1.59–3.90)
|
-
|
1.12 (0.98–1.28)
|
|
Anxiety/ Depression
|
Non-problematic
|
1 (ref.)
|
-
|
1 (ref.)
|
-
|
|
Problematic
|
1.18 (0.71–1.94)
|
-
|
1.04 (0.95–1.13)
|
-
|
|
Health scale (VAS)
|
1.00 (0.98–1.01)
|
1.00 (0.99–1.01)
|
1.00 (1.00–1.00)
|
1.00 (1.00–1.00)
|
|
Pseudo R2
|
0.27
|
0.09
|
0.04
|
0.07
|
Statistical analyses conducted using logistic regressions for homecare services use and allied health services use and using negative binomial regressions for number of GP–patient contacts in the last 12 months and the number of specialist's consulted, adjusting for all the variables indicated. °CIRS = Cumulative illness rating scale. °°TBQ = Treatment burden questionnaire.