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PubMed2005

Prevalence and distinct correlates of anxiety, substance, and combined comorbidity in a multi-site public sector sample with bipolar disorder.

BACKGROUND: Recent data indicate high prevalence of both anxiety and substance comorbidity in bipolar disorder. However, few studies have utilized public sector samples, and only one has attempted to separate contributions of each type of comorbidity. METHODS: 328 inpatient veterans with bipolar disorder across 11 sites were assessed using selected Structured Clinical Interview for DSM-IV modules and self-reports. RESULTS: Comorbidity was common (current: 57.3%; lifetime: 78.4%), with multiple current comorbidities in 29.8%. Substance comorbidity rate was comparable to rates typically reported in non-veteran inpatient samples (33.8% current, 72.3% lifetime). Selected anxiety comorbidity rates exceeded those in other inpatient samples and appeared more chronic than episodic/recurrent (38.3% current, 43.3% lifetime). 49% of PTSD was due to non-combat stressors. Major correlates of current substance comorbidity alone were younger age, worse marital status, and higher current employability. Correlates of current anxiety comorbidity alone were early age of onset, greater number of prior-year depressive episodes, higher rates of disability pension receipt, and lower self-reported mental and physical function. Combined comorbidity resembled anxiety comorbidity. LIMITATIONS: This is a cross-sectional analysis of acutely hospitalized veterans. CONCLUSIONS: Distinct patterns of substance and anxiety comorbidity are striking, and may be subserved by distinct neurobiologic mechanisms. The prevalence, chronicity and functional impact of anxiety disorders indicate the need for improved recognition and treatment of this other dual diagnosis group is warranted. Clinical and research interventions should recognize these divergent comorbidity patterns and provide individualized treatment built "from the patient out."

Adult↗

PubMed2002

Validity of information on comorbidity derived rom ICD-9-CCM administrative data.

BACKGROUND: The comorbidity variables that constitute the Charlson index are widely used in health care research using administrative data. However, little is known about the validity of administrative data in these comorbidities. The agreement between administrative hospital discharge data and chart data for the recording of information on comorbidity was evaluated. The predictive ability of comorbidity information in the two data sets for predicting in-hospital mortality was also compared. METHODS: One thousand two hundred administrative hospital discharge records were randomly selected in the region of Calgary, Alberta, Canada in 1996 and used a published coding algorithm to define the 17 comorbidities that constitute the Charlson index. Corresponding patient charts for the selected records were reviewed as the "criterion standard" against which validity of the administrative data were judged. RESULTS: Compared with the chart data, administrative data had a lower prevalence in 10 comorbidities, a higher prevalence in 3 and a similar prevalence in 4. The kappa values ranged from a high of 0.87 to a low of 0.34; agreement was therefore near perfect for one variable, substantial for six, moderate for nine, and only fair for one variable. For the Charlson index score ranging from 0 to 5 to 6 or higher, agreement was moderate to substantial (kappa = 0.56, weighted kappa = 0.71). When 16 Charlson comorbidities from administrative data were used to predict in-hospital mortality, 10 comorbidities and the index scores defined using administrative data yielded odds ratios that were similar to those derived from chart data. The remaining six comorbidities yielded odds ratios that were quite different from those derived from chart data. CONCLUSIONS: Administrative data generally agree with patient chart data for recording of comorbidities although comorbidities tend to be under-reported in administrative data. The ability to predict in-hospital mortality is less reliable for some of the individual comorbidities than it is for the summarized Charlson index scores in administrative data.

Abstracting and Indexing↗

PubMed2004

Prevalence of comorbid psychiatric illness and substance misuse in primary care in England and Wales.

STUDY OBJECTIVE: To estimate the annual period prevalence of co-occurring psychiatric illness and substance misuse among patients in primary care. DESIGN: Analysis of the general practice research database. SETTING: England and Wales, 1993-1998. PARTICIPANTS: Registered patients at 230 general practices representing 3.1% of the population. A comorbid case was defined as one with both a psychiatric diagnosis and substance misuse diagnosis (not including alcohol or tobacco) within a calendar year. A potentially chronic comorbid case was one that met this definition and, in addition, was treated in subsequent years for either a psychiatric condition or substance misuse. MAIN RESULTS: The annual period prevalence of comorbidity increased from 50/100 000 patient years of exposure (PYE) to 80/100 000 PYE, an increase of 62% during the study period. Rates of comorbid psychoses, comorbid schizophrenia, and comorbid paranoia increased by 147%, 128%, and 144%. The average age of comorbid cases decreased from 38 years to 34 years. Over 80% of comorbid cases were newly diagnosed in each study year, although many are treated in subsequent years for either psychiatric illness or substance misuse. CONCLUSIONS: This study provides data on the nature and extent of comorbidity in primary care in England and Wales. As the comorbidity rate is increasing by about 10% each year, and as comorbid cases are becoming younger, it is probable that the comorbidity rate will have increased beyond the study end point.

Adolescent↗

PubMed2006

Comorbidity and physical function: results from the aging and longevity study in the Sirente geographic area (ilSIRENTE study).

BACKGROUND: Physical function measures have gained increased importance in the evaluation of older persons. The presence of comorbidity is a major and growing issue in geriatrics. OBJECTIVE: To evaluate the relationship between comorbidity and physical function in community-dwelling older persons. METHODS: Data are from baseline evaluation of the ilSIRENTE study (n = 364). Physical performance was assessed using the Short Physical Performance Battery (SPPB) and the 4-meter walking test. Muscle strength was measured by hand-grip strength. Functional performance was assessed using Basic and Instrumental Activities of Daily Living (ADLs and IADLs, respectively). Comorbidity was defined as >or=3 clinical conditions. Analyses of covariance and linear regressions were performed to evaluate the relationship between comorbidity and physical function. RESULTS: The mean age of participants was 85.9 (SD = 4.9) years. About one third (37.4%) of participants reported >or=3 clinical conditions. Participants with comorbidity had significantly worse results in all the physical function tests. Participants with comorbidity had significantly lower adjusted results for the 4-meter walking test (0.444 m/s) and the SPPB score (6.131) compared to those without comorbidity (0.531 m/s and 7.221; all p = 0.001, respectively). Participants with comorbidity were more IADL-impaired (3.152) than participants without comorbidity (2.767; p = 0.04). No significant association of ADLs and hand-grip strength with comorbidity was reported. Similar strengths of association for the 4-meter walking test (per SD increase, beta = -0.280; p = 0.001) and the SPPB (per SD increase, beta = -0.285; p = 0.001) with comorbidity were reported. CONCLUSIONS: Physical function measures, especially walking speed and SPPB, are associated with comorbidity. Physical performance measures may improve the clinical evaluation of older persons.

Activities of Daily Living↗

PubMed2005

Impact of comorbid panic and posttraumatic stress disorder on outcomes of collaborative care for late-life depression in primary care.

OBJECTIVE: Comorbid anxiety disorders may result in worse depression treatment outcomes. The authors evaluated the effect of comorbid panic disorder and posttraumatic stress disorder (PTSD) on response to a collaborative-care intervention for late-life depression in primary care. METHODS: A total of 1,801 older adults with depression were randomized to a collaborative-care depression treatment model versus usual care and assessed at baseline, 3, 6, and 12 months, comparing differences among participants with comorbid panic disorder (N=262) and PTSD (N=191) and those without such comorbid anxiety disorders. RESULTS: At baseline, patients with comorbid anxiety reported higher levels of psychiatric and medical illness, greater functional impairment, and lower quality of life. Participants without comorbid anxiety who received collaborative care had early and lasting improvements in depression compared with those in usual care. Participants with comorbid panic disorder showed similar outcomes, whereas those with comorbid PTSD showed a more delayed response, requiring 12 months of intervention to show a significant effect. At 12 months, however, outcomes were comparable. Interactions of intervention status by comorbid PTSD or panic disorder were not statistically significant, suggesting that the collaborative-care model performed significantly better than usual care in depressed older adults both with and without comorbid anxiety. CONCLUSIONS: Collaborative care is more effective than usual care for depressed older adults with and without comorbid panic disorder and PTSD, although a sustained treatment response was slower to emerge for participants with PTSD. Intensive and prolonged follow-up may be needed for depressed older adults with comorbid PTSD.

Age Factors↗

PubMed2006

Comorbidity in patients with diabetes mellitus: impact on medical health care utilization.

BACKGROUND: Comorbidity has been shown to intensify health care utilization and to increase medical care costs for patients with diabetes. However, most studies have been focused on one health care service, mainly hospital care, or limited their analyses to one additional comorbid disease, or the data were based on self-reported questionnaires instead of health care registration data. The purpose of this study is to estimate the effects a broad spectrum of of comorbidities on the type and volume of medical health care utilization of patients with diabetes. METHODS: By linking general practice and hospital based registrations in the Netherlands, data on comorbidity and health care utilization of patients with diabetes (n = 7,499) were obtained. Comorbidity was defined as diabetes-related comorbiiabetes-related comorbidity. Multilevel regression analyses were applied to estimate the effects of comorbidity on health care utilization. RESULTS: Our results show that both diabetes-related and non diabetes-related comorbidity increase the use of medical care substantially in patients with diabetes. Having both diabeterelated and non diabetes-related comorbidity incrases the demand for health care even more. Differences in health care utilization patterns were observed between the comorbidities. CONCLUSION: Non diabetes-related comorbidity increases the health care demand as much as diabetes-related comorbidity. Current single-disease approach of integrated diabetes care should be extended with additional care modules, which must be generic and include multiple diseases in order to meet the complex health care demands of patients with diabetes in the future.

Adult↗

PubMed2005

Comorbid conditions in kidney transplantation: association with graft and patient survival.

Although the impact of comorbidity on outcomes in ESRD has been evaluated extensively, its contribution after kidney transplantation has not been well studied. It is believed that comorbidity assessment is critical to the informed interpretation of kidney transplant outcomes. In this study, the Charlson Comorbidity Index was used to assess the comorbid conditions of 715 patients who underwent kidney transplantation at the Starzl Transplant Institute between January 1998 and January 2003. The impact of pretransplantation comorbidity on the development of acute cellular rejection after transplantation and on patient and graft survival was examined. The most common comorbid conditions among our patient population were diabetes (n = 217, 30.3%) and heart failure (n = 85, 11.9%). It was found the number of patients with high comorbidity at the Starzl Transplant Institute has increased significantly over time (P = 0.04). In multivariate adjusted models, high comorbidity was associated with an increased risk for patient death, both in the perioperative period (hazard ratio 3.20, 95% confidence interval 1.32 to 7.78; P = 0.01) and >3 mo after transplantation (hazard ratio 2.63; 95% confidence interval 1.62 to 4.28; P < 0.001). The Charlson Comorbidity Index is a practical tool for the evaluation of comorbidity in the transplant population, which has an increasing burden of comorbid disease. Increased comorbidity affects both perioperative and long-term patient outcomes and carries significant implications not only for the development of individual patient therapeutic strategies but also for the interpretation of patient trials and the development of policies that govern distribution of donor organs.

Adult↗

PubMed2005

Influence of psychiatric comorbidity in alcohol-dependent subjects in a representative population survey on treatment utilization and natural recovery.

BACKGROUND: It is well known that only a minority of alcohol-dependent subjects seek help and that the majority of alcohol-dependent individuals recover without utilization of formal help. Psychiatric comorbidity is highly prevalent among alcohol-dependent individuals. However, no data are available on the impact of psychiatric comorbidity on natural recovery. AIMS: To analyse the impact of non-psychotic psychiatric comorbid Axis I disorders on remission rate and utilization of formal help in alcohol-dependent individuals drawn from a representative general population sample in northern Germany (response rate: 70.2%, n = 4075). Psychiatric diagnoses and utilization of help were assessed in a personal interview using standardized instruments. One hundred and fifty-three life-time alcohol-dependent individuals were assessed, among whom 98 fulfilled the criteria for sustained long-term remission according to the Diagnostic and Statistical Manual version II (DSM-IV) criteria. Any coincidence of DSM-IV non-psychotic Axis I disorders with alcohol dependence was counted as comorbidity. Comorbidity rate in the whole sample was 36.1%. RESULTS: The rate of individuals who remitted from alcohol dependence without formal help was 36.9% in the non-comorbid and 42.6% in the comorbid group. Utilization of formal help was unrelated to comorbidity. Dually diagnosed subjects without a history of help-seeking showed minor differences concerning reasons for not seeking help. Seeking help was not related to schooling, severity of dependence and gender. CONCLUSION: Data reveal that remission without formal help is equally prevalent among non-comorbid as among comorbid alcohol-dependent individuals. Axis I comorbidity is not related directly to utilization of alcohol-related help. Negative prognoses for untreated comorbid alcohol-dependent individuals are not justified from an epidemiological point of view.

Adolescent↗

PubMed2006

Effect of medical comorbidity on self-assessed pain, function, and general health status after rotator cuff repair.

BACKGROUND: In a previous study, we found that medical comorbidities have a negative effect on preoperative pain, function, and general health status in patients with a chronic rotator cuff tear. In this study, we evaluated the relationship between medical comorbidities and the postoperative outcome of rotator cuff repair. METHODS: One hundred and twenty-five patients were evaluated on the basis of a history (including medical comorbidities) and use of outcome tools preoperatively and at one year after rotator cuff repair. Outcome was evaluated with the Disabilities of the Arm, Shoulder and Hand (DASH) Questionnaire, the Simple Shoulder Test (SST), visual analog scales (pain, function, and quality of life), and the Short Form-36 (SF-36). RESULTS: The mean number of medical comorbidities was 1.91 (range, zero to six). At one year after rotator cuff repair, there were no significant correlations between comorbidities and pain, shoulder function, or quality of life as determined with the SST, DASH, and visual analog scales (p > 0.05). A greater number of comorbidities was associated with a worse postoperative general health status (SF-36 role emotional [p = 0.045], SF-36 bodily pain [p = 0.032], SF-36 general health [p = 0.001], and SF-36 vitality [p = 0.033]). Nevertheless, a greater number of comorbidities was associated with greater improvement, compared with the preoperative status, in the pain score on the visual analog scale (p = 0.009), function as assessed with the visual analog scale (p = 0.022) and the DASH (p = 0.044), and quality of life as assessed with the visual analog scale (p = 0.041). CONCLUSIONS: Patients with more medical comorbidities have a worse general health status after rotator cuff repair. Interestingly, it also appears that these patients have greater improvement in overall shoulder pain, function, and quality-of-life scores compared with preoperative scores. Therefore, despite a negative effect of comorbidities on outcomes, patients with more comorbidities have greater improvement after the repair, to the point where postoperative shoulder function and pain are not significantly influenced by medical comorbidities. Consequently, a higher number of medical comorbidities should not be considered a negative factor in determining whether a patient should undergo rotator cuff repair.

Adult↗

PubMed1996

Comorbid anxiety disorder and the functioning and well-being of chronically ill patients of general medical providers.

BACKGROUND: The comorbidity of psychiatric disorders with chronic health conditions has emerged as a topic of considerable clinical and policy interest, in part owing to the evidence that anxiety disorders themselves are associated with morbidity. However, the implications for health-related quality of life that result from anxiety disorders, which are comorbid to chronic medical or psychiatric illness, are not well understood, especially in primary care samples. METHODS: A 2-year observational study of 875 adult patients with hypertension, diabetes, heart disease, and current depressive disorder or subthreshold depression receiving care from general medical providers was conducted. The unique effect of any comorbid anxiety disorder on functioning and well-being (determined with the use of the 36-Item Short-Form Health Survey [SF-36]) was estimated, as well as the differential impact at baseline, 2-year follow-up, and change over time, of any comorbid anxiety disorder for patients with chronic medical conditions or depression. RESULTS: Patients with comorbid anxiety who received general medical care had lower levels of functioning and well-being than those without comorbid anxiety. These differences were most pronounced in mental health-related quality-of-life measures and when anxiety was comorbid with chronic medical conditions rather than with depression. Hypertensive and diabetic patients with comorbid anxiety were as debilitated as patients with depression or heart disease, and this low health-related quality of life persisted over time. Comorbid anxiety had less of an effect on patients with heart disease who already had a low health-related quality of life. CONCLUSION: The finding of substantial differences in the quality of life between hypertensive and diabetic patients with and without comorbid anxiety disorder highlights the clinical and societal importance of identifying comorbid anxiety in these patients.

Adult↗

PubMed2006

The influence of age and comorbidity on receiving radiotherapy as part of primary treatment for cancer in South Netherlands, 1995 to 2002.

BACKGROUND: The objective of this study was to study the influence of age and comorbidity on receiving radiotherapy (RT) in primary treatment of cancer. METHODS: In a population-based setting, the authors calculated the proportion of irradiated patients within 6 months after they received a diagnosis of lung, rectal, breast, or prostate cancer or non-Hodgkin lymphoma (n = 33,369 patients) according to age and comorbidity between 1995 and 2002. Logistic regression analysis was used to adjust for age, comorbidity, gender, and stage. RESULTS: Patients with localized nonsmall cell lung cancer (NSCLC) ages 65 years to > or = 80 years or with comorbid conditions received RT alone significantly more often compared with younger patients (ages 65-79 years: odds ratio [OR], 3.4; age > or = 80: OR, 12.0) and patients without comorbidities (1 comorbid condition: OR, 2.1; > or = 2 comorbid conditions: OR, 2.4). This also applied to patients with nonlocalized NSCLC ages 65 years to 79 years compared with younger patients (OR, 1.4). RT was administered significantly less often to elderly patients with resected rectal cancers (ages 65-79 years: OR, 0.7; age > or = 80 years: OR, 0.4), patients age > or = 80 years with breast cancer after undergoing conserving surgery (OR, 0.1), and patients age > or = 80 years with clinical T1-T3,N0,M0 prostate cancer age (OR, 0.1) compared with younger patients. Patients with breast cancer who underwent breast-conserving surgery received RT significantly less often in the presence of comorbidities (1 comorbid condition: OR, 0.6; > or = 2 comorbid conditions: OR, 0.4). Older patients with aggressive non-Hodgkin lymphoma received only RT as treatment significantly more often compared with younger patients (OR, 3.4). CONCLUSIONS: Comorbidity and age did have influence over whether patients received RT, although, for most tumor types, age appeared to be a stronger predicting factor. Under treatment was observed among patients with breast cancer and rectal cancer.

Age Factors↗

PubMed2005

Impact of two different comorbidity measures on the 6-month mortality of critically ill cancer patients.

OBJECTIVE: To evaluate the impact of two different comorbidity measures on the 6-month mortality of severely ill cancer patients. DESIGN AND SETTING: Prospective cohort study in a ten-bed oncological medical-surgical intensive care unit (ICU). PATIENTS: A total of 772 consecutive patients were included over a 45-month period. The mean age was 57.6+/-16.4 years, and 642 (83%) patients had solid tumors. MEASUREMENTS AND RESULTS: Data were collected on admission and during ICU stay. Comorbidities were evaluated using the Charlson Comorbidity Index (CCI) and the Adult Comorbidity Evaluation (ACE-27). The ICU, hospital, and 6-month mortality rates were 34%, 47%, and 58%, respectively. The most frequent comorbidities were hypertension (33%), diabetes mellitus (8%), and chronic pulmonary disease (7%). There were important differences between the two indices regarding the comorbidity evaluation. Using the ACE-27, 389 patients (50%) had comorbid ailments that were classified as mild (31%), moderate (14%), and severe (5%) according to the comorbidity severity. According to the CCI, 212 patients (27%) had a comorbidity, and their median score was 1 (1-2). In the multivariable Cox proportional hazard models only the presence of a severe comorbidity by the ACE-27 was associated with increased mortality. The CCI was not independently associated with the outcome. Other outcome predictors were older age, poor performance status, active cancer, need of mechanical ventilation, and severity of acute organ failures. CONCLUSIONS: Severe comorbidities must be considered in the outcome evaluation of ICU cancer patients. The ACE-27 seems to be a useful instrument for prognostic assessment in this population.

Adult↗

PubMed2006

Comorbidity of PTSD and depression following myocardial infarction.

BACKGROUND: This study examines comorbidity of posttraumatic stress disorder (PTSD) and depression following myocardial infarction (MI). It has two aims: (a) to examine whether this comorbidity is predicted by the objective severity of the MI and the patients' initial appraisal and stress responses; and (b) to determine whether this comorbidity is associated with PTSD symptomatology, depression, physiological adjustment, and psychosocial adjustment seven months post-MI. METHOD: 116 MI patients were examined twice. At Time 1, within a week of the MI, initial appraisal, stress responses, and depressive reactions were assessed, and medical measures were obtained from patients' hospital records. At Time 2, seven months later, PTSD, depression, psychosocial functioning, and physical adjustment were assessed. RESULTS: Seven months post-MI, 16% of the patients were identified with PTSD; 8% with comorbid PTSD and depression; and 14% with high levels of depression without full PTSD. Initial level of depression was associated with comorbidity of PTSD and depression. While initial stress reactions did not predict comorbidity, they did predict depression, with or without comorbid PTSD. Comorbidity of PTSD and depression was associated with higher levels of adjustment difficulties. DISCUSSION: Comorbidity of PTSD and depression has some clinical significance. While initial level of depression predicts subsequent comorbidity of PTSD and depression, early stress reactions do not differentiate between MI patients who suffer from depression, with or without comorbid PTSD.

Activities of Daily Living↗

PubMedDate not supplied

Affective and anxiety comorbidity in post-traumatic stress disorder treatment trials of sertraline.

Comorbidity of mood and anxiety disorders is common in patients suffering from post-traumatic stress disorder (PTSD). The current study evaluated the efficacy and tolerability of sertraline in a subgroup of PTSD patients suffering from anxiety or depression comorbidity. Two multicenter, 12-week, double-blind, flexible-dose US studies of adult outpatients from the general population with a DSM-III-R diagnosis of PTSD evaluated the safety and efficacy of sertraline (50 to 200 mg/d) compared to placebo in the treatment of PTSD. The total severity score of the Clinician-Administered PTSD Scale (CAPS-2) and the Davidson Trauma Scale (DTS) were used to examine the effect of comorbidity on treatment outcome. Among the combined 395 subjects enrolled in the two trials, 32.9% had a comorbid depressive diagnosis (no anxiety diagnosis), 6.3% had a comorbid anxiety disorder diagnosis (no depression), 11.4% had both a depression and anxiety disorder diagnosis, and 49.4% had no comorbidity. The correlation, at baseline, between Hamilton Depression Rating Scale (HAM-D) total score and the three CAPS-2 clusters was 0.37 for the re-experiencing/intrusion cluster, 0.52 for the avoidance/numbing cluster, and 0.45 for the hyperarousal cluster. Patients suffering from PTSD complicated by a current diagnosis of both depression and an anxiety disorder showed the highest baseline CAPS-2 cluster score severity. Patients treated with sertraline improved significantly (P <.05) compared to placebo on both the CAPS-2 and DTS whether or not they had a comorbid depressive or anxiety disorder. Sertraline was well tolerated. The presence of comorbidity was associated with a modest and mostly nonspecific increase in the side effect burden of approximately 10% to 20% on both study treatments. Patients suffering from dual depression and anxiety disorder comorbidity benefited from somewhat higher doses (147 mg v 125 mg; P =.08). Similarly, the presence of dual comorbidity resulted in a modest but nonsignificant increase in the mean time to response from 4.5 weeks to 5.5 weeks. We conclude that sertraline (50 to 200 mg/d) is effective and well tolerated in the treatment of PTSD for patients suffering from a current, comorbid depressive or anxiety disorders.

Adult↗

PubMed1996

Comorbidity and breast cancer survival: a comparison between black and white women.

The presence of concurrent health conditions (comorbidity) at the time of breast cancer diagnosis has an adverse effect on survival. It is unclear, however, whether the strength of the association between comorbidity and survival varies in different populations of breast cancer patients. It is necessary, therefore, to establish (1) whether a comorbidity index derived from a general population of patients (mostly white) would predict survival in a black population, and (2) whether comorbidity would have the same degree of relationship to mortality in black as in white populations. We studied 1196 breast cancer patients who were members of the Kaiser Permanente Medical Care Program and were diagnosed with local (n = 708), regional (n = 446), or remote (n = 49) stage breast cancer from 1973 to 1986. Mortality follow-up was completed to December 1994. Ten-year survival was studied in relation to the Charlson comorbidity index for black women and for white women, and for both groups of women combined. Compared to women with a Charlson comorbidity score of 0 (no comorbidity), patients with scores of 1, 2, and 3+ had risk ratios for ten-year mortality of 1.23 (P = 0.10), 2.58 (P < 0.001), and 3.44 (P < 0.001), respectively. This pattern of risk associated with comorbidity was similar to that found in the original Charlson study. The pattern of risk ratios for different levels of comorbidity was very similar for black and white patients. The results confirm previous studies indicating that comorbidity (in particular, the Charlson Comorbidity Index) predicts the survival of women with breast cancer, independently of other factors, such as stage of breast cancer at diagnosis. The Charlson index has prognostic significance for both black and white populations. Research is needed to determine whether the Charlson index can be improved by including health conditions that are particularly prevalent or severe in specific subgroups of women.

Aged↗

PubMed2001

Comorbidity assessment using the Index of Coexistent Diseases in a multicenter clinical trial.

BACKGROUND: The Hemodialysis (HEMO) Study is a multicenter trial designed to determine whether hemodialysis dose and membrane flux affect survival. Comorbid conditions are also important determinants of survival, and thus, an accurate and reliable method to assess comorbidity was required. Comorbidity was being assessed at baseline and annually in the HEMO Study using the Index of Coexistent Disease (ICED). We describe the instrument, its implementation in the HEMO Study, and the results of comorbidity assessment in the first 1000 randomized patients in the trial. METHODS: The ICED aggregated the presence and severity of 19 medical conditions and 11 physical impairments within two scales: the Index of Disease Severity (IDS) and the Index of Physical Impairment (IPI). The final ICED score was determined by an algorithm combining the peak scores for the IDS and IPI. The range of the ICED was from 0 to 3, reflecting increasing severity. RESULTS: Study personnel at 15 clinical centers were trained to update and abstract data from the dialysis medical records. Availability of data, measures of construct validity, and measures of reliability were adequate; 99.8% and 60.6% of patients had comorbid conditions in at least one IDS or IPI category, respectively. The distribution of patients by ICED level was 0 (0.2%), 1 (34.9%), 2 (31.2%), and 3 (33.7%). In multivariable analysis, the following factors were significantly associated with more severe comorbidity: older age, diabetes and other causes of renal disease, a lower level of education, employment status (unemployed and retired), longer duration of dialysis, and lower serum creatinine. There was a significant variation in the severity of comorbidity among clinical centers after adjustment for other factors. The R2 of the model was 25.3%, indicating that a substantial proportion of the variation in the ICED was not explained by these factors. CONCLUSIONS: We conclude that comorbidity assessment using the ICED is feasible in multicenter clinical trials of dialysis patients. There is a large burden of comorbidity in dialysis patients, which is not well explained by the cause of renal disease, demographic, and socioeconomic factors and common clinical and laboratory measurements. These variables should not be considered substitutes for comorbid conditions in case-mix adjustment. Comorbidity assessment is useful to describe the sample population, to improve the precision of the treatment effect, and to use possibly as an outcome measurement.

Comorbidity↗

PubMed2004

Predicting 1 year mortality in an outpatient haemodialysis population: a comparison of comorbidity instruments.

BACKGROUND: A valid and practical measure of comorbid illness burden in dialysis populations is greatly needed to enable unbiased comparisons of clinical outcomes. We compare the discriminatory accuracy of 1 year mortality predictions derived from four comorbidity instruments in a large representative US dialysis population. METHODS: Comorbidity information was collected using the Index of Coexistent Diseases (ICED) in 1779 haemodialysis patients of a national dialysis provider between 1997 and 2000. Comorbidity was also scored according to the Charlson Comorbidity Index (CCI), Wright-Khan and Davies indices. Relationships of instrument scores with 1 year mortality were assessed in separate logistic regression analyses. Discriminatory ability was compared using the area under the receiver-operating characteristics curve (AUC), based on predictions of each regression model. RESULTS: When mortality was predicted using comorbidity and age, the ICED better discriminated between survivors and those who died (AUC 0.72) as compared with the CCI (0.67), Wright-Khan (0.68) and Davies (0.68) indices. Upon addition of race and serum albumin, predictive accuracy of each model improved further (AUCs of the ICED, 0.77; CCI, 0.75; Wright-Khan Index, 0.75; Davies Index, 0.74). CONCLUSIONS: The ICED had greater discriminatory ability than the CCI, Davies and Wright-Khan indices, when age and a comorbidity index were used alone to predict 1 year mortality; however, the differences among instruments diminished once serum albumin, race and the cause of ESRD were accounted for. None of the currently available comorbidity instruments tested in this study discriminated mortality outcomes particularly well. Assessing comorbidity using the ICED takes significantly more time. Identifying the key prognostic comorbid conditions and weighting these according to outcomes in a dialysis population should increase accuracy and, with restriction to a finite number of items, provide a practical means for widespread comorbidity assessment.

Cause of Death↗

PubMed1997

Comorbidity in ADHD: implications for research, practice, and DSM-V.

OBJECTIVE: Since the introduction of DSM-III/III-R, clinicians and investigators have shown increasing interest in the study of conditions comorbid with attention-deficit hyperactivity disorder (ADHD). Better understanding ADHD comorbidity patterns is needed to guide treatment, research and future classification approaches. METHOD: The ADHD literature from the past 15 years was reviewed to (1) explore the most prevalent patterns of ADHD comorbidity; (2) examine the correlates and longitudinal predictors of comorbidity; and (3) determine the extent to which comorbid patterns convey unique information concerning ADHD etiology, treatment and outcomes. To identify potential new syndromes, the authors examined comorbid patterns based on eight validational criteria. RESULTS: The largest available body of literature concerned the comorbidity with ADHD and conduct disorder/aggression, with a substantially smaller amount of data concerning other comorbid conditions. In many areas the literature was sparse, and pertinent questions concerning comorbidity patterns remain unexplored. Nonetheless available data warrant the delineation of two new subclassifications of ADHD: (1) ADHD aggressive subtype, and (2) ADHD, anxious subtype. CONCLUSIONS: Additional studies of the frequency of comorbidity and associated factors are greatly needed to include studies of differential effects of treatment of children with various comorbid ADHD disorders, as well as of ADHD children who differ on etiological factors.

Aggression↗