| BackgroundIn recent years,chronic diseases have been co-existing with humans for a long period of time,making global health care systems face enormous challenge.In 2019,the number of chronic patients dying in China accounted for 88.5%of the total number of deaths,exceeding the global average.Four types of diseases,cardiovascular and cerebrovascular diseases,malignant tumors,chronic respiratory diseases and diabetes,are the main causes of death from chronic diseases.Multimorbidity is the presence of two or more chronic diseases in the same patient.Multimorbidity increases the demand for medical resources,the burden of disease and the risk of death for patients.The etiology of chronic diseases is complex,often due to the interaction of multiple risk factors,and the co-existence of multiple chronic diseases adds to their complexity.Identifying specific multimorbidity patterns can help doctors predict a patient’s risk of developing multimorbidity and explore possible interactions between different chronic conditions.The understanding of multimorbidity in China is still at a preliminary stage and disease management tends to focus on single chronic diseases,lacking an integrated strategy for the management of multimorbidity.Therefore,this study is of practical significance to comprehensively understand the current status of chronic diseases patients’ multimorbidity,explore different multimorbidity patterns and related factors of multimorbidity,pay attention to the mortality and potential risk factors,and analyze the correlation between multimorbidity and death.ObjectiveA cross-sectional study and a follow-up study through a face-to-face questionnaire and the public health management system service information platform were used to understand the current status of multimorbidity,explore common multimorbidity patterns and analyze the related factors of multimorbidity in patients aged 45 years and above with chronic diseases in Huangdao District.This study also wanted to analyze the risk factors for death and the correlation between multimorbidity and death in patients with chronic diseases,and makes recommendations for the prevention,control and management of patients with chronic diseases.Methods1.Study populationThe population of the study were from the "Comprehensive Prevention and Control Project of Hypertension and Diabetes for All Populations" in Huangdao District,Shandong Province.5,294 patients with chronic diseases were surveyed by questionnaire in 75 villages in 17 towns and streets in Huangdao District in 2015.Chronic diseases and deaths of study population were supplemented through the public health management system service information platform.2.Statistical analysisAll data processing and analysis for this study were done through EXCEL,SPSS 24.0,R 4.2.2(including the ’tableone’ package,the ’arules’ package,the ’survival’ package)and Gephi 0.9.5.1)Underlying characteristics were described using frequency(percentages)and differences were analyzed using the χ2 test/rank sum test for comparison between single chronic disease patients and multimorbidity patients.2)The correlations and strength of association between chronic diseases were analyzed using the association rule Apriori algorithm,and common multimorbidity patterns were screened out and visualized and analyzed in the multimorbidity network with the aid of Gephi 0.9.5 software.The related factors of multimorbidity were analyzed by Logistic regression,and the presence of multicollinearity among indicators was tested by variance inflation factor,and finally the fit of the model was tested using Hosmer-Lemeshow.3)The Kaplan-Meier method was used to plot the cumulative mortality curves of the study population,and Log-Rank was used to test for differences in the cumulative mortality curves of different subgroups.Cox proportional risk regression models were used to analyze the factors influencing mortality and the association between multimorbidity and mortality,and Schoenfeld covariates were used to detect proportional risk assumptions.Results1.General information of the study populationThis study included 5294 population,included 1926 males,accounting for 36.38%,and 3368 females,accounting for 63.62%.There were 1904 patients with a single chronic disease,accounting for 35.97%,and 3390 patients with multimorbidity,accounting for 64.03%.The number of multimorbidity was mainly two and three.Statistical differences existed between patients with multimorbidity and patients with single chronic disease in terms of gender,age,marital status,education level,occupational status,work intensity,smoking status,alcohol consumption,fruit intake status,vegetable intake status and taste preference(P<0.05).2.Common multimorbidity patternsThe most common binary multimorbidity patterns in this study were coronary heart disease+hypertension,stroke + hypertension,and digestive system disease+hypertension.The most common ternary multimorbidity patterns were coronary heart disease+stroke+hypertension,coronary heart disease+digestive system disease+hypertension,and stroke+digestive system disease+hypertension.The multimorbidity network graph suggested that the core disease of multimorbidity in this population was hypertension,with complex associations between chronic diseases.3.Related factors of multimorbidityCompared with patients with single chronic disease,univariate Logistic regression analysis showed that female,≥60 years,divorced/widowed,primary school education level and above,non-farmer,no physical work,overweight or obese,previous smoking,previous alcohol consumption,always alcohol consumption,regular fruit consumption,vegetable intake≥500 grams per day,and salty taste were statistically associated with multimorbidity(P<0.05).Multivariable Logistic regression analysis showed that female,≥60 years,no physical work,overweight or obese,previous smoking,previous alcohol consumption and salty taste were positively associated with multimorbidity,while regular fruit consumption was negatively associated with multimorbidity(P<0.05).The Hosmer-Lemeshow test statistic for this model was 9.94,with a degree of freedom of 8,P=0.270,and the model fit was good.4.Mortality,influencing factors and correlation between multimorbidity and mortalityFrom July 2015 to December 2020,there were 181 deaths,a cumulative mortality rate of 3.42%over 65 months and an average annual mortality rate of 0.63%,with 95.03%of deaths mainly due to chronic diseases.Statistical differences in age,smoking status and alcohol consumption between patients with a single chronic condition and patients with multimorbidity among the death(P<0.05).Univariate Cox regression analysis showed that female,≥60 years,unmarried,divorced/widowed,primary school education level and above,non-farmer,moderate physical work,light physical work,underweight,overweight or obesity,previous smoking,always smoking,previous alcohol consumption,regular fruit consumption,vegetable intake≥ 500 grams per day,and red meat only were statistically associated with death(P<0.05).Multivariable Cox regression analysis showed that the risk of death was 1.99 times in ≥60 years patients as in 45～59 years patients(HR=1.99,95%CI:1.07-3.69);1.76 times in divorced/widowed patients as in married patients(HR=1.76,95%CI:1.07-2.90);2.43 times in patients with low weight as in patients with normal weight(HR=2.43,95%CI:1.25-4.73);2.09 times in patients who had been smoking as in non-smokers(HR=2.09,95%CI:1.12-3.90);2.15 times in patients who had previously consumed alcohol as in those who had not(HR=2.15,95%CI:1.13-4.06).Having five or more chronic diseases increased the risk of death,but this association was not statistically significant after adjusting for gender and age.Conclusions1.A high proportion of chronic disease patients had multimorbidity and women were higher than men.The number of multimorbidity was mainly two and three.2.The coronary heart disease+hypertension,stroke+hypertension,and digestive system disease+hypertension were the most common binary multimorbidity patterns;The coronary heart disease+stroke+hypertension,coronary heart disease+digestive system disease+hypertension,and stroke+digestive system disease+hypertension were the most common ternary multimorbidity patterns.The core disease of multimorbidity in this population was hypertension and the multimorbidity situation was complex.3.The related factors of multimorbidity were gender,age,work intensity,body mass index,smoking status,alcohol consumption,taste preference and fruit intake status.Female,≥60 years old,no physical work,overweight or obesity,previous smoking,previous alcohol consumption,and salty taste were positively associated with multimorbidity;while regular fruit consumption was negatively associated with multimorbidity.4.The number of deaths from chronic diseases was higher among patients with chronic diseases.The factors influencing death were age,marital status,body mass index,smoking status and alcohol consumption. |
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