Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA.
Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA.
J Gerontol A Biol Sci Med Sci. 2021 Aug 13;76(9):1668-1677. doi: 10.1093/gerona/glaa314.
Multimorbidity is common in adults aged 65 and older and is associated with health care utilization and mortality, but most methods ignore the interrelationship among concurrent outcome nor provide person-specific probabilities.
A longitudinal cohort of 5300 older Americans from the 2011-2015 rounds of the National Health and Aging Study was linked to Center for Medicare and Medicaid Services claims. Odds ratios for 15 chronic conditions adjusted for sociodemographic factors were estimated using a joint model of hospitalization, skilled nursing facility (SNF) admission, and mortality. Additionally, we estimated the person-specific probability of an outcome while currently at risk for other outcomes for different chronic disease combinations demonstrating the heterogeneity across persons with identical chronic conditions.
During the 4-year follow-up period, 2867 (54.1%) individuals were hospitalized, 1029 (19.4%) were admitted to a SNF, and 1237 (23.3%) died. Chronic kidney disease, dementia, heart failure, and chronic obstructive pulmonary disease had significant increased odds for all 3 outcomes. By incorporating a person-specific random intercept, there was considerable range of person-specific probabilities for individuals with hypertension, diabetes, and depression with dementia, (hospitalization: 0.14-0.61; SNF admission: 0.04-0.28) and without dementia (hospitalization: 0.07-0.44; SNF admission: 0.02-0.15). Such heterogeneity was found among individuals with heart failure, ischemic heart disease, chronic kidney disease, hypertension, hyperlipidemia, and osteoarthritis with and without Medicare.
This approach of joint modeling of interrelated concurrent health care and mortality outcomes not only provides a cohort-level odds and probabilities but addresses the heterogeneity among otherwise similarly characterized persons identifying those with above-average probability of poor outcomes.
65 岁及以上的成年人中多病共存很常见，与医疗保健的使用和死亡率有关，但大多数方法忽略了同时发生的结果之间的相互关系，也没有提供针对个体的概率。
对来自国家健康老龄化研究 2011-2015 年各轮的 5300 名美国老年人进行了一项纵向队列研究，并与医疗保险和医疗补助服务中心的索赔数据相关联。使用住院、熟练护理机构（SNF）入院和死亡的联合模型，对调整了社会人口因素的 15 种慢性疾病的调整比值比进行了估计。此外，我们还针对不同的慢性疾病组合，在当前面临其他结果风险的情况下，估计了个体发生结果的特定概率，从而展示了具有相同慢性疾病的个体之间的异质性。
在 4 年的随访期间，2867 人（54.1%）住院，1029 人（19.4%）入住 SNF，1237 人（23.3%）死亡。慢性肾脏病、痴呆、心力衰竭和慢性阻塞性肺疾病对所有 3 种结果的发生几率都有显著增加。通过纳入个体特定的随机截距，患有高血压、糖尿病和抑郁症伴痴呆的个体的个体特定概率范围较大（住院：0.14-0.61；SNF 入院：0.04-0.28），而不伴痴呆的个体的个体特定概率范围较小（住院：0.07-0.44；SNF 入院：0.02-0.15）。在伴有或不伴有医疗保险的心力衰竭、缺血性心脏病、慢性肾脏病、高血压、高血脂症和骨关节炎的个体中，都发现了这种异质性。
这种联合建模同时发生的相关医疗保健和死亡率结果的方法不仅提供了队列水平的比值比和概率，而且还解决了否则具有相似特征的个体之间的异质性，确定了那些发生不良结果的概率较高的个体。
