Lancet：65岁以下患者常同时患多种疾病

近日，苏格兰邓迪大学人口健康科学部的Karen Barnett博士及其同事通过回顾苏格兰2007年314家初级保健诊所登记的1,751,841例患者的病历，了解40种慢性疾病单独发生和共同发生的情况。42%的入组患者患有≥1种疾病，23%患有多种疾病。相关论文于5月10日在Lancet杂志发表。

在所有患者和合并多病患者中，分别有8.3%和36%同时患有躯体和心理疾病。罹患躯体疾病的种数越多并且社会经济地位越低，则患慢性心理疾病的风险越高。同时患有身心疾病的65岁以下患者的绝对数量(n=90,139)多于65岁以上患者(n=55,912)。合并多种疾病的65岁以下患者的绝对数量(n=210,500)多于65岁以上患者(n=194,966)。在社会经济地位最低的年轻和中年成人中观察到的多种合并症的发生率与在年龄大10~15岁的最富有患者中观察到的结果相同。心理疾病是导致贫穷患者合并多种疾病的最主要因素，在最贫穷患者和最富有患者中的发生率分别为11%和5.9%。

该研究的局限性在于主要依据初级保健医生记录的数据，因此可能有一些合并症未被记录，从而导致研究结果低估合并多种疾病的真实发生率。另外，目前尚无测定合并多种疾病的标准方法。

在随刊述评中，英国布里斯托尔大学社会和社区医学院的Chris Salisbury博士指出，随着医疗体系的结构性改变，对合并多种疾病者的治疗变得更加困难。为了提高质量，对慢性疾病越来越多地在专科医院内遵照指南推荐的方案进行治疗，而这些指南所依据的研究大多未纳入合并多病患者。不过，通过采取以下措施可加强对合并症的治疗：延长初级保健咨询服务的时间、向医学生传授更多有关慢性疾病及疾病间相互作用的知识，以及减少不发达地区医生的诊治量。另外，根据指南制定个体化的治疗方案也很重要。

该研究获苏格兰政府资助。Barnett博士及其同事声明无经济利益冲突。Salisbury博士亦声明无经济利益冲突。（生物谷Bioon.com）

doi:10.1016/S0140- 6736[12]60240-2
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Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study

Original TextKaren Barnett PhD a, Prof Stewart W Mercer PhD b, Michael Norbury MBChB a, Prof Graham Watt MD b, Prof Sally Wyke PhD c, Prof Bruce Guthrie PhD a

Summary

Background

Long-term disorders are the main challenge facing health-care systems worldwide, but health systems are largely configured for individual diseases rather than multimorbidity. We examined the distribution of multimorbidity, and of comorbidity of physical and mental health disorders, in relation to age and socioeconomic deprivation.

Methods

In a cross-sectional study we extracted data on 40 morbidities from a database of 1 751 841 people registered with 314 medical practices in Scotland as of March, 2007. We analysed the data according to the number of morbidities, disorder type (physical or mental), sex, age, and socioeconomic status. We defined multimorbidity as the presence of two or more disorders.

Findings

42·2% (95% CI 42·1—42·3) of all patients had one or more morbidities, and 23·2% (23·08—23·21) were multimorbid. Although the prevalence of multimorbidity increased substantially with age and was present in most people aged 65 years and older, the absolute number of people with multimorbidity was higher in those younger than 65 years (210 500 vs 194 996). Onset of multimorbidity occurred 10—15 years earlier in people living in the most deprived areas compared with the most affluent, with socioeconomic deprivation particularly associated with multimorbidity that included mental health disorders (prevalence of both physical and mental health disorder 11·0%, 95% CI 10·9—11·2% in most deprived area vs 5·9%, 5·8%—6·0% in least deprived). The presence of a mental health disorder increased as the number of physical morbidities increased (adjusted odds ratio 6·74, 95% CI 6·59—6·90 for five or more disorders vs 1·95, 1·93—1·98 for one disorder), and was much greater in more deprived than in less deprived people (2·28, 2·21—2·32 vs 1·08, 1·05—1·11).

Interpretation

Our findings challenge the single-disease framework by which most health care, medical research, and medical education is configured. A complementary strategy is needed, supporting generalist clinicians to provide personalised, comprehensive continuity of care, especially in socioeconomically deprived areas.

Funding

Scottish Government Chief Scientist Office.