The good news is that life expectancy is increasing around the world and we are all living longer. The less good news is that as we get older, we are acquiring a growing number of chronic diseases.
Multimorbidity—defined as the presence of two or more conditions in an individual—is increasingly common. It presents a number of challenges for patients and healthcare professionals, particularly as our systems and research are so focused on single conditions.
A recently published clinical review on the management of multimorbidity looks at some of these issues and how they can be managed in primary care.
Take guidelines, for example. Guidelines are usually based on evidence from randomised controlled trials. Very often, trials exclude older people and people with multiple chronic conditions. As the review describes, it is therefore difficult to apply single condition guidelines to people with multimorbidity:
“Consider the application of five UK clinical guidelines for a hypothetical 78 year old woman with previous myocardial infarction, type 2 diabetes, osteoarthritis, chronic obstructive pulmonary disease, and depression. She would be prescribed a minimum of 11 drugs, with potentially up to 10 others recommended depending on symptoms and progression of disease, and she would be advised to engage in at least nine lifestyle modifications. In addition to any unplanned appointments, she would be expected to annually attend 8-10 routine primary care appointments for her physical conditions and 8-30 psychosocial intervention appointments for depression and advised to attend multiple appointments for smoking cessation support and pulmonary rehabilitation.”
Many patients and clinicians will recognise this scenario and the challenges it illustrates: a high treatment burden on patients, fragmentation of care, polypharmacy, and a likely lack of patient centred care and shared decision making. We need to ask patients about what matters to them and prioritise accordingly, say the authors of the clinical review, as well as use our clinical judgement to determine when to stray from guidelines and targets.
In a podcast accompanying the clinical review, I asked two of the authors, Emma Wallace and Susan Smith, to describe the ideal healthcare system that could better serve patients with multimorbidity. Number one on the agenda? A single medical record that could be shared across disciplines and specialties.
Also on the wishlist are better communication between professionals, more time to spend with patients, more geriatricians and general physicians, and a fully functioning primary care team that includes physiotherapists, occupational therapists, and psychologists. Sign me up to work in the Wallace and Smith Health Service.
Until this dream healthcare system becomes a reality, the clinical review and podcast offer a number of practice points to help those in primary care manage complex multimorbidity.
If you’re interested in multimorbidity and the issues raised by the clinical review, take a look at some of these previously published articles in The BMJ:
- We need minimally disruptive medicine—Victor Montori and colleagues call for the care of people with complex multimorbidity to become less burdensome and more collaborative.
- Adapting clinical guidelines to take account of multimorbidity—Bruce Guthrie and colleagues describe how the care of people with multimorbidity can be improved by using new technology to bring together guidelines on individual conditions and tailor advice to each patient’s circumstances.
- Better management of patients with multimorbidity—Clinical judgement and an emphasis on continuity of care is needed, say Martin Roland and Charlotte Paddison.
- Discontinuing drug treatments—Sarah Hilmer and colleagues argue that more evidence is needed to guide deprescribing.
Navjoyt Ladher is clinical editor, The BMJ. Follow Navjoyt on Twitter, @dire_tribe