Multimorbidity – the presence of two or more long-term health conditions or chronic diseases – has a greater impact on risk of all causes of death in middle-aged men, as opposed to older populations, according to new research.
The study, led by the University of Glasgow in the United Kingdom and published in the journal BMC Medicine, also found that multimorbidity is associated with a higher risk of death from cancer, vascular conditions and all causes of death, even after accounting for lifestyle or demographic factors.
However, absolute mortality remains higher in the 60- to 73-years age group.
The effect of multiple long-term conditions in increasing mortality risk was largest among men aged 37 to 49 years.
A link between cardiovascular multimorbidity and cancer death was also found.
The researchers, from the university’s Institute of Health and Wellbeing, also found that the type of long-term condition a person has – as opposed to the number of conditions – may have an important role to play in understanding the relationship between multimorbidity and death.
Corresponding author of the study and Norie Miller Professor of General Practice Dr Frances Mair said: “This study is significant because it presents novel findings regarding what we know about multimorbidity.
“This is the first study to examine the relationship of multimorbidity with cancer mortality and we have shown a dose-response relationship between number of long-term conditions (LTCs) and cancer mortality.”
Lead author Dr Bhautesh Jani said: “Younger participants, especially men, were observed to have a relatively higher risk of mortality with increasing number of LTCs, and certain combinations of conditions were associated with a particularly higher risk of death.
“Going forward, further research is needed to study the impact and management of multimorbidity in middle-aged adults, as they may be at higher risk of early death.”
Overall, the study found that for those with four or more LTCs, combinations that included cardiometabolic conditions, chronic kidney disease, cancer, epilepsy, chronic obstructive pulmonary disease, depression, osteoporosis and connective tissue disorders, had the greatest impact on all causes of death.
Cardiometabolic conditions include hypertension, coronary heart disease, peripheral vascular disease, atrial fibrillation, diabetes, heart failure, and stroke or a transient ischaemic attack.
In comparison to participants with no LTCs, participants with one LTC were nearly one-and-a-half times more likely to die, participants with two LTCs were more than one-and-a-half times more likely to die, participants with three LTCs were more than twice as likely to die, and participants with four or more LTCs were nearly three times more likely to die, over the median of seven years follow-up.
While socioeconomic status remained an independent and significant predictor of all-cause mortality, the relationship between multimorbidity and mortality risk was consistent across all categories of socioeconomic status.
The study was a prospective population-based cohort study, which included 502,640 participants enrolled in the UK Biobank from 22 different assessment centres across England, Scotland and Wales between 2006 and 2010.
A catastrophic illness is a severe illness that requires prolonged hospitalisation and/or recovery, for example, heart attack, stroke, cancers, etc.
These illnesses incur high expenditure for the patient, family and healthcare facility, and may incapacitate the patient from working, leading to catastrophic health expenditure.
According to the World Health Organization (WHO), “a household has catastrophic health expenditure (CHE) when its out-of-pocket health payments equal or exceed 40% of its non-subsistence expenditure, or what is called its capacity to pay”.
CHE is associated with some households having to borrow money or sell assets to finance their healthcare; earning less due to deteriorated health condition(s); are impoverished after paying for healthcare services; and some households who are already below the poverty line, become even poorer due to healthcare payment.
The reports of CHE studies in Malaysia are disturbing, to say the least.
A multi-institutional team studied whether current health coverage extended to catastrophic illnesses that inevitably incur CHE and found that the coverage varies from universal for dialysis, cataract surgery, medicines for organ transplant and chronic myeloid leukaemia, to practically none for hepatitis C, stroke, psoriasis and epilepsy surgery.
Coverage of targeted therapies for solid cancers, knee replacement surgery, anti-tumour necrosis factor for arthritis and coagulation factors for haemophilia were poor, while iron chelation for thalassaemia, coronary revascularisation, epoetin and anti-retrovirals were barely adequate.
The authors concluded: “Coverage for catastrophically costly treatments is uneven and inequitable in Malaysia, despite most of these being affordable. Decisions on coverage are driven by political-economic consideration.”
The 2012–2014 Asean Costs in Oncology Study prospectively followed-up 9,513 newly diagnosed cancer patients from eight countries for 12 months.
The overall and country-specific incidence of financial catastrophe, i.e. out-of-pocket health costs (equal or more than 30% of annual household income), economic hardship (inability to make necessary household payments), poverty (living below the national poverty line) and all-cause mortality, were determined.
The study found that the proportion of previously-solvent patients who experienced economic hardship following a cancer diagnosis was highest in Malaysia (45%) and Indonesia (42%,) and lowest in Thailand (16%).
A prospective study of 138 colorectal cancer (CRC) patients at University Malaya Medical Centre estimated the cost of CRC treatment, and the prevalence and determinants of CHE.
The patients were interviewed at the time of the diagnosis, and subsequently at six and 12 months following diagnosis.
It was found that the mean cost of CRC treatment was RM8,306 (US$2,595), and 47.8% of patients’ families experienced CHE.
The main determinants of CHE were the family’s economic status and the patient’s likelihood of undergoing surgery.
The authors concluded that the study “strongly suggests that stakeholders and policymakers should provide individuals with financial protection against the consequences of cancer, a costly illness that often requires prolonged treatment”.
Heart attacks, strokes, cancer and many other diseases can result in catastrophic health expenditure for many patients. — AFP
Another study involved 503 patients hospitalised at the National Heart Institute (IJN) during the year prior to the survey.
It was found that “almost 16% suffered from CHE, 29.2% were unable to pay for medical bills, 25.0% withdrew savings to help meet living expenses, 16.5% reduced their monthly food consumption, 12.5% were unable to pay utility bills and 9.0% borrowed money to help meet living expenses”.
The authors concluded that the economic impact of ischaemic heart disease (IHD) in Malaysia “was considerable and the prospect of economic hardship likely to persist over the years due to the long-standing nature of IHD.
“The findings highlight the need to evaluate the present health financing system in Malaysia and to expand its safety net coverage for vulnerable patients”.
CHE also affected the parents of children with rotavirus gastroenteritis.
A two-year prospective, hospital-based study was conducted from 2008 to 2010 in Kuala Lumpur and Kuala Terengganu.
All 658 children under the age of five years admitted for acute gastroenteritis were included. Patients were screened for rotavirus and information on healthcare expenditure was obtained.
The mean direct and indirect costs for rotavirus gastroenteritis of 248 children consisted 20% of monthly household income in Kuala Lumpur, compared to 5% in Kuala Terengganu.
Direct medical costs paid out-of-pocket caused 141 (33%) households in Kuala Lumpur to experience CHE and 11 (3%) households to incur poverty, but in Kuala Terengganu, only one household (0.5%) experienced CHE and none were impoverished.
The authors concluded: “While urban households were wealthier, healthcare expenditure due to gastroenteritis had more catastrophic and poverty impact on the urban poor.
“Universal rotavirus vaccination would reduce both disease burden and health inequities in Malaysia.”
The print and electronic media disclosed on Aug 16, 2018, the Health Ministry’s Pharmaceutical Services Programme announcement on its website of the temporary suspension of the Patient Access Scheme (PASc), pending advice from the Auditor General.
The PASc involves free provision of drugs to patients with cancer and rare diseases in public hospitals.
The Health Minister had to allay the anxiety of patients currently on these drugs and protests from civil society.
It is evident that CHE is a serious problem that will become more prevalent if ignored.
The common refrain in the conclusions of the published studies is that the State needs to provide financial protection for those who develop catastrophic illnesses.
In the endeavour to have universal health coverage, the Govern-ment would have to ensure that any form of state-sponsored social insurance would include provisions for CHE, particularly for the low and middle income groups.
Dr Milton Lum is a past president of the Federation of Private Medical Practitioners Associations and the Malaysian Medical Association. The views expressed do not represent that of organisations that the writer is associated with. The information provided is for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.