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1.  Unhealthy lifestyles do not mediate the relationship between socioeconomic status and incident depressive symptoms; The Health ABC study 
Background
The relationship between low socioeconomic status (SES) and depressive symptoms is well described, also in older persons. Although studies have found associations between low SES and unhealthy lifestyle factors and between unhealthy lifestyle factors and depressive symptoms, not much is known about unhealthy lifestyles as a potential explanation of socioeconomic differences in depressive symptoms in older persons.
Methods
To study the independent pathways between SES (education, income, perceived income, and financial assets), lifestyle factors (smoking, alcohol use, body mass index, and physical activity), and incident depressive symptoms (CES-D 10 and reported use of antidepressant medication), we used 9 years of follow-up data (1997–2007) from 2,694 American black and white participants aged 70–79 from the Health, Aging, and Body Composition (Health ABC) study. At baseline, 12.1% of the study population showed prevalent depressive symptoms, use of antidepressant medication, or treatment of depression in the five years prior to baseline. These persons were excluded from the analyses.
Results
Over a period of 9 years time, 860 participants (31.9%) developed depressive symptoms. Adjusted hazard ratios for incident depressive symptoms were higher in participants from lower SES groups compared to the highest SES group. The strongest relationships were found for black men. Although unhealthy lifestyle factors were consistently associated with low SES, they were weakly related to incident depressive symptoms. Lifestyle factors did not significantly reduce hazard ratios for depressive symptoms by SES.
Conclusion
In generally healthy persons aged 70–79 years lifestyle factors do not explain the relationship between SES and depressive symptoms. (250)
doi:10.1016/j.jagp.2013.01.004
PMCID: PMC3402597  PMID: 23567402
Health ABC study; Socioeconomic status; Lifestyle factors; Depressive symptoms; Elderly; United States
2.  Similar Multimorbidity Patterns in Primary Care Patients from Two European Regions: Results of a Factor Analysis 
PLoS ONE  2014;9(6):e100375.
Objective
To compare the similarities among the multimorbidity patterns identified in primary care patients from two European regions (Spain and the Netherlands) with similar organisational features of their primary care systems, using validated methodologies.
Methodology
This observational, retrospective, multicentre study analysed information from primary care electronic medical records. Multimorbidity patterns were assessed using exploratory factor analysis of the diagnostic information of patients over 14 years of age. The analysis was stratified by age groups and sex.
Results
The analysis of Dutch data revealed a higher prevalence of multimorbidity which corresponds with the clustering of a higher number of diseases in each of the patterns. Relevant clinical similarities were found between both countries for three multimorbidity patterns that were previously identified in the original Spanish study: cardiometabolic, mechanical and psychiatric-substance abuse. In addition, the clinical evolution towards complexity of the cardiometabolic pattern with advancing age -already demonstrated in the original study- was corroborated in the Dutch context. A clear association between mechanical and psychosocial disorders was unique to the Dutch population, as well as the recurrent presentation of the psychiatric-substance abuse pattern in all age and sex groups.
Conclusions
The similarities found for the cardiometabolic, mechanical and psychiatric-substance abuse patterns in primary care patients from two different European countries could offer initial clues for the elaboration of clinical practice guidelines, if further evidenced in other contexts. This study also endorses the use of primary care electronic medical records for the epidemiologic characterization of multimorbidity.
doi:10.1371/journal.pone.0100375
PMCID: PMC4067297  PMID: 24956475
3.  Cancer in the Elderly 
Journal of Cancer Epidemiology  2014;2014:872029.
doi:10.1155/2014/872029
PMCID: PMC4021674  PMID: 24876840
4.  Four screening instruments for frailty in older patients with and without cancer: a diagnostic study 
BMC Geriatrics  2014;14:26.
Background
Frailty in older patients might influence treatment decisions. Frailty can be determined using a Comprehensive Geriatric Assessment (CGA), but this is time-consuming and expensive. Therefore we assessed the diagnostic value of four shorter screening instruments.
Methods
We tested the abbreviated CGA (aCGA), the Vulnerable Elders Survey-13 (VES-13), the Groningen Frailty Indicator (GFI) and the Geriatric 8 (G8). A full CGA including functional status, cognitive status, depression, nutrition and comorbidity was used as reference. A minimum of 85% for both sensitivity and specificity was predefined as acceptable. Data were collected through personal interviews by trained interviewers. We assessed people aged ≥ 70 years: 108 patients with recently diagnosed cancer recruited in hospitals and 290 without cancer recruited by general practitioners in the Netherlands and Belgium.
Frailty was defined as having impairment in at least two domains of the full CGA. We used original cut-offs for the screening instruments and calculated sensitivity, specificity, positive and negative diagnostic values and the percentage classified as frail.
Results
Sensitivity of aCGA was 79% and 87% for patients with and without cancer; specificity was 59% and 64%. Sensitivity of VES-13 was 67% and 82% for patients with and without cancer; specificity was 70% and 79%. Sensitivity for GFI was 76% (in both groups) and specificity 73% (in both groups). Sensitivity for G8 was 87% and 75% for patients with and without cancer; specificity was 68% (in both groups).
Conclusions
No screening instrument was acceptable according to our predefined minimum of 85% for both sensitivity and specificity. The diagnostic value of the investigated instruments is rather poor and one could wonder about their additional value to clinical judgment.
doi:10.1186/1471-2318-14-26
PMCID: PMC3938903  PMID: 24571290
Frailty; Screening; Geriatric assessment; Cancer
5.  Predictability of Persistent Frequent Attendance in Primary Care: A Temporal and Geographical Validation Study 
PLoS ONE  2013;8(9):e73125.
Background
Frequent attenders are patients who visit their general practitioner exceptionally frequently. Frequent attendance is usually transitory, but some frequent attenders become persistent. Clinically, prediction of persistent frequent attendance is useful to target treatment at underlying diseases or problems. Scientifically it is useful for the selection of high-risk populations for trials. We previously developed a model to predict which frequent attenders become persistent.
Aim
To validate an existing prediction model for persistent frequent attendance that uses information solely from General Practitioners’ electronic medical records.
Methods
We applied the existing model (N = 3,045, 2003–2005) to a later time frame (2009–2011) in the original derivation network (N = 4,032, temporal validation) and to patients of another network (SMILE; 2007–2009, N = 5,462, temporal and geographical validation). Model improvement was studied by adding three new predictors (presence of medically unexplained problems, prescriptions of psychoactive drugs and antibiotics). Finally, we derived a model on the three data sets combined (N = 12,539). We expressed discrimination using histograms of the predicted values and the concordance-statistic (c-statistic) and calibration using the calibration slope (1 = ideal) and Hosmer-Lemeshow tests.
Results
The existing model (c-statistic 0.67) discriminated moderately with predicted values between 7.5 and 50 percent and c-statistics of 0.62 and 0.63, for validation in the original network and SMILE network, respectively. Calibration (0.99 originally) was better in SMILE than in the original network (slopes 0.84 and 0.65, respectively). Adding information on the three new predictors did not importantly improve the model (c-statistics 0.64 and 0.63, respectively). Performance of the model based on the combined data was similar (c-statistic 0.65).
Conclusion
This external validation study showed that persistent frequent attenders can be prospectively identified moderately well using data solely from patients’ electronic medical records.
doi:10.1371/journal.pone.0073125
PMCID: PMC3764153  PMID: 24039870
6.  Socioeconomic factors from midlife predict mobility limitation and depressed mood three decades later; Findings from the AGES-Reykjavik Study 
BMC Public Health  2013;13:101.
Background
Taking into account our rapidly ageing population, older people are of particular interest in studying health inequalities. Most studies of older persons only include measures of current socioeconomic status (SES) and do not take into account data from earlier stages of life. In addition, only classic SES measures are used, while alternative measures, such as car ownership and house ownership, might equally well predict health. The present study aims to examine the effect of midlife socioeconomic factors on mobility limitation and depressed mood three decades later.
Methods
Data were from 4,809 men and women aged 33–65 years who participated in the Reykjavik Study (1967–1992) and who were re-examined in old age in the Age, Gene/Environment Susceptibility (AGES) -Reykjavik Study (2002–2006).
Results
Education and occupation predicted mobility limitation and depressed mood. Independently, home and car ownership and the availability of housing features predicted mobility limitation. Shortages of food in childhood and lack of a car in midlife predicted depressed mood.
Conclusion
Socioeconomic factors from midlife and from childhood affect mobility limitation and depressed mood in old age. Prevention of health problems in old age should begin as early as midlife.
doi:10.1186/1471-2458-13-101
PMCID: PMC3599346  PMID: 23379351
Socioeconomic status; Mobility limitation; Depressed mood; Midlife; Old age
7.  Perceived unfairness and socioeconomic inequalities in functional decline: the Dutch SMILE prospective cohort study 
BMC Public Health  2012;12:818.
Background
People in lower socioeconomic positions report worse health-related functioning. Only few examined whether perceptions of unfairness are particularly common in these people and whether this perceived unfairness relates to their subsequent poor health outcomes. We thus set out to examine the contribution of perceived unfairness to the higher risks of physical and mental dysfunction in men and women with a lower socioeconomic position.
Methods
Seven-year prospective cohort data from the Dutch SMILE study among 1,282 persons, 55 years old and older, were used. Physical and mental health-related functioning was measured with the SF-36, socioeconomic status with income and education, and the perception of unfairness with an extended new measure asking for such perceptions in both work and non-work domains.
Results
Perceived unfairness was more common in lower socioeconomic positions. Such perpection was related to both physical (odds ratio = 1.57 (95% confidence interval: 1.17-2.11)) and mental (1.47 (1.07-2.03)) decline, while low socioeconomic position was only related to mental decline (1.33 (1.06-1.67)). When socioeconomic position and perceived unfairness were simultaneously controlled, odds ratios for both determinants decreased only very little. Socioeconomic position and perceived unfairness were for the largest part independently related to longitudinal health-related decline.
Conclusions
The general perception of unfairness, at work and beyond work, might have implications for functional decline in middle and older age. We recommend that – rather than addressing and changing individual perceptions of unfairness – more research is needed to find out whether specific environments can be defined as unfair and whether such environments can be effectively tackled in an attempt to truly improve public health.
doi:10.1186/1471-2458-12-818
PMCID: PMC3502084  PMID: 22998808
Perceived unfairness; Socioeconomic differences in health; Health-related functioning
8.  Chronic Diseases among Older Cancer Survivors 
Journal of Cancer Epidemiology  2012;2012:206414.
Objective. To compare the occurrence of pre-existing and subsequent comorbidity among older cancer patients (≥60 years) with older non-cancer patients. Material and Methods. Each cancer patient (n = 3835, mean age 72) was matched with four non-cancer patients in terms of age, sex, and practice. The occurrence of chronic diseases was assessed cross-sectionally (lifetime prevalence at time of diagnosis) and longitudinally (incidence after diagnosis) for all cancer patients and for breast, prostate, and colorectal cancer patients separately. Cancer and non-cancer patients were compared using logistic and Cox regression analysis. Results. The occurrence of the most common pre-existing and incident chronic diseases was largely similar in cancer and non-cancer patients, except for pre-existing COPD (OR 1.21, 95% CI 1.06–1.37) and subsequent venous thrombosis in the first two years after cancer diagnosis (HR 4.20, 95% CI 2.74–6.44), which were significantly more frequent (P < 0.01) among older cancer compared to non-cancer patients. Conclusion. The frequency of multimorbidity in older cancer patients is high. However, apart from COPD and venous thrombosis, the incidence of chronic diseases in older cancer patients is similar compared to non-cancer patients of the same age, sex, and practice.
doi:10.1155/2012/206414
PMCID: PMC3432539  PMID: 22956953
9.  Excess of health care use in general practice and of comorbid chronic conditions in cancer patients compared to controls 
BMC Family Practice  2012;13:60.
Background
The number of cancer patients and the number of patients surviving initial treatments is expected to rise. Traditionally, follow-up monitoring takes place in secondary care. The contribution of general practice is less visible and not clearly defined.
This study aimed to compare healthcare use in general practice of patients with cancer during the follow-up phase compared with patients without cancer. We also examined the influence of comorbid conditions on healthcare utilisation by these patients in general practice.
Methods
We compared health care use of N=8,703 cancer patients with an age and gender-matched control group of patients without cancer from the same practice. Data originate from the Netherlands Information Network of General Practice (LINH), a representative network consisting of 92 general practices with 350,000 enlisted patients. Health care utilisation was assessed using data on contacts with general practice, prescription and referral rates recorded between 1/1/2001 and 31/12/2007. The existence of additional comorbid chronic conditions (ICPC coded) was taken into account.
Results
Compared to matched controls, cancer patients had more contacts with their GP-practice (19.5 vs. 11.9, p<.01), more consultations with the GP (3.5 vs. 2.7, p<.01), more home visits (1.6 vs. 0.4, p<.01) and they got more medicines prescribed (18.7 vs. 11.6, p<.01) during the follow-up phase. Cancer patients more often had a chronic condition than their matched controls (52% vs. 44%, p<.01). Having a chronic condition increased health care use for both patients with and without cancer. Cancer patients with a comorbid condition had the highest health care use.
Conclusion
We found that cancer patients in the follow-up phase consulted general practice more often and suffered more often from comorbid chronic conditions, compared to patients without cancer. It is expected that the number of cancer patients will rise in the years to come and that primary health care professionals will be more involved in follow-up care. Care for comorbid chronic conditions, communication between specialists and GPs, and coordination of tasks then need special attention.
doi:10.1186/1471-2296-13-60
PMCID: PMC3480891  PMID: 22712888
Neoplasms; Cancer; Primary health care; General practitioner; Follow-up; Comorbidity
10.  Study protocol of KLIMOP: a cohort study on the wellbeing of older cancer patients in Belgium and the Netherlands 
BMC Public Health  2011;11:825.
Background
Cancer is mainly a disease of older patients. In older cancer patients, additional endpoints such as quality of survival and daily functioning might be considered equally relevant as overall or disease free survival. However, these factors have been understudied using prospective designs focussing on older cancer patients. Therefore, this study will focus on the impact of cancer, ageing, and their interaction on the long-term wellbeing of older cancer patients.
Methods/Design
This study is an observational cohort study. We aim to recruit 720 cancer patients above 70 years with a new diagnosis of breast, prostate, lung or gastrointestinal cancer and two control groups: one control group of 720 patients above 70 years without a previous diagnosis of cancer and one control group of 720 cancer patients between 50 - 69 years newly diagnosed with breast, prostate, lung or gastrointestinal cancer. Data collection will take place at inclusion, after six months, after one year and every subsequent year until death or end of the study. Data will be collected through personal interviews (consisting of socio-demographic information, general health information, a comprehensive geriatric assessment, quality of life, health locus of control and a loneliness scale), a handgrip test, assessment of medical records, two buccal swabs and a blood sample from cancer patients (at baseline). As an annex study, caregivers of the participants will be recruited as well. Data collection for caregivers will consist of a self-administered questionnaire examining depression, coping, and burden.
Discussion
This extensive data collection will increase insight on how wellbeing of older cancer patients is affected by cancer (diagnosis and treatment), ageing, and their interaction. Results may provide new insights, which might contribute to the improvement of care for older cancer patients.
doi:10.1186/1471-2458-11-825
PMCID: PMC3215168  PMID: 22026575
11.  Better health reports when the grass is greener on your side of the fence? A cross-sectional study in older persons 
Objective
To study whether the luxury goods make older people feel in better health and whether this association is similar in higher and lower social classes.
Methods
SMILE consists of a Dutch general population consisting of 2.637 men and women aged 60 years and older in 2007. The SF-36 was used to measure health-related functioning.
Results
In the lower social class, having many luxury goods was related to feeling in better physical (OR 2.06, 95% CI 1.39–3.07) and mental health (OR 1.79, 95% CI 1.21–2.64), but not in the higher social class.
Conclusions
There might be a health benefit of keeping up appearances, snobbism, and “conspicuous consumption” in older people from lower social classes.
doi:10.1007/s00038-010-0176-x
PMCID: PMC3144365  PMID: 20697768
Socioeconomic inequalities; Health; Older persons
12.  Learning and Caring in Communities of Practice: Using Relationships and Collective Learning to Improve Primary Care for Patients with Multimorbidity 
Annals of family medicine  2010;8(2):170-177.
We introduce a primary care practice model for caring for patients with multimorbidity. Primary care for these patients requires flexibility and ongoing coordination, and it often must be tailored to individual circumstances. Such complex and flexible care could be accomplished within communities of practice, whose participants are willing to learn from their shared practice, further each other’s goals, share their stories of success and failure, and promote the continued evolution of collective learning. Primary care in these communities would be conceived as a complex adaptive process in which the participants use an iterative approach to care improvement that integrates what they learn and do collectively over time. Clinicians in these communities would define common goals, cocreate care plans, and engage in reflective case-based learning. As community members manage their knowledge, gain insights, and develop new care strategies, they can improve care for patients with multiple conditions. Using a mix of methods, future research should explore the conditions that are necessary for collective learning within communities of clinicians who care for patients with multimorbidity and who develop new knowledge in practice. By understanding these conditions, we can foster the development of collective learning and improve primary care for these patients.
doi:10.1370/afm.1056
PMCID: PMC2834724  PMID: 20212304 CAMSID: cams1140
Primary health care; multimorbidity; community of practice; interprofessional practice; collective learning; complex adaptive systems
13.  Multimorbidity's many challenges 
BMJ : British Medical Journal  2007;334(7602):1016-1017.
Time to focus on the needs of this vulnerable and growing population
doi:10.1136/bmj.39201.463819.2C
PMCID: PMC1871747  PMID: 17510108
14.  Lack of basic and luxury goods and health-related dysfunction in older persons; Findings from the longitudinal SMILE study 
BMC Public Health  2008;8:242.
Background
More so than the traditional socioeconomic indicators, such as education and income, wealth reflects the accumulation of resources and makes socioeconomic ranking manifest and explicitly visible to the outside world. While the lack of basic goods, such as a refrigerator, may affect health directly, via biological pathways, the lack of luxury goods, such as an LCD television, may affect health indirectly through psychosocial mechanisms. We set out to examine, firstly, the relevance of both basic and luxury goods in explaining health-related dysfunction in older persons, and, secondly, the extent to which these associations are independent of traditional socioeconomic indicators.
Methods
Cross-sectional and longitudinal data from 2067 men and women aged 55 years and older who participated in the Study on Medical Information and Lifestyles Eindhoven (SMILE) were gathered. Logistic regression analyses were used to study the relation between a lack of basic and luxury goods and health-related function, assessed with two sub-domains of the SF-36.
Results
The lack of basic goods was closely related to incident physical (OR = 2.32) and mental (OR = 2.12) dysfunction, even when the traditional measures of socioeconomic status, i.e. education or income, were taken into account. Cross-sectional analyses, in which basic and luxury goods were compared, showed that the lack of basic goods was strongly associated with mental dysfunction. Lack of luxury goods was, however, not related to dysfunction.
Conclusion
Even in a relatively wealthy country like the Netherlands, the lack of certain basic goods is not uncommon. More importantly, lack of basic goods, as an indicator of wealth, was strongly related to health-related dysfunction also when traditional measures of socioeconomic status were taken into account. In contrast, no effects of luxury goods on physical or mental dysfunction were found. Future longitudinal research is necessary to clarify the precise mechanisms underlying these effects.
doi:10.1186/1471-2458-8-242
PMCID: PMC2483978  PMID: 18637182
15.  The SMILE study: a study of medical information and lifestyles in Eindhoven, the rationale and contents of a large prospective dynamic cohort study 
BMC Public Health  2008;8:19.
Background
Health problems, health behavior, and the consequences of bad health are often intertwined. There is a growing need among physicians, researchers and policy makers to obtain a comprehensive insight into the mutual influences of different health related, institutional and environmental concepts and their collective developmental processes over time.
Methods/Design
SMILE is a large prospective cohort study, focusing on a broad range of aspects of disease, health and lifestyles of people living in Eindhoven, the Netherlands. This study is unique in its kind, because two data collection strategies are combined: first data on morbidity, mortality, medication prescriptions, and use of care facilities are continuously registered using electronic medical records in nine primary health care centers. Data are extracted regularly on an anonymous basis. Secondly, information about lifestyles and the determinants of (ill) health, sociodemographic, psychological and sociological characteristics and consequences of chronic disease are gathered on a regular basis by means of extensive patient questionnaires. The target population consisted of over 30,000 patients aged 12 years and older enrolled in the participating primary health care centers.
Discussion
Despite our relatively low response rates, we trust that, because of the longitudinal character of the study and the high absolute number of participants, our database contains a valuable set of information.
SMILE is a longitudinal cohort with a long follow-up period (15 years). The long follow-up and the unique combination of the two data collection strategies will enable us to disentangle causal relationships. Furthermore, patient-reported characteristics can be related to self-reported health, as well as to more validated physician registered morbidity. Finally, this population can be used as a sampling frame for intervention studies. Sampling can either be based on the presence of certain diseases, or on specific lifestyles or other patient characteristics.
doi:10.1186/1471-2458-8-19
PMCID: PMC2254401  PMID: 18208599
16.  A meta-analysis on depression and subsequent cancer risk 
Background
The authors tested the hypothesis that depression is a possible factor influencing the course of cancer by reviewing prospective epidemiological studies and calculating summary relative risks.
Methods
Studies were identified by computerized searches of Medline, Embase and PsycINFO. as well as manual searches of reference lists of selected publications. Inclusion criteria were cohort design, population-based sample, structured measurement of depression and outcome of cancer known for depressed and non-depressed subjects
Results
Thirteen eligible studies were identified. Based on eight studies with complete crude data on overall cancer, our summary relative risk (95% confidence interval) was 1.19 (1.06–1.32). After adjustment for confounders we pooled a summary relative risk of 1.12 (0.99–1.26).
No significant association was found between depression and subsequent breast cancer risk, based on seven heterogeneous studies, with or without adjustment for possible confounders. Subgroup analysis of studies with a follow-up of ten years or more, however, resulted in a statistically significant summary relative risk of 2.50 (1.06–5.91).
No significant associations were found for lung, colon or prostate cancer.
Conclusion
This review suggests a tendency towards a small and marginally significant association between depression and subsequent overall cancer risk and towards a stronger increase of breast cancer risk emerging many years after a previous depression.
doi:10.1186/1745-0179-3-29
PMCID: PMC2235847  PMID: 18053168

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