MultimorbidityIsitreallysomethingnew?
DrRokasNavickasConsultantcardiologist
VilniusUniversityHospitalSantariskiuKlinikosMultimorbidityWPco-leader,CHRODISJointActionProgramme
EuropeanHealthForumGastein201530092015
What’sthechallenge?
* Vogeli C, Shields AE, Lee TA, Gibson TB, Marder WD, Weiss KB, et al. Multiple chronic conditions: prevalence, healthconsequences,andimplicationsforquality,caremanagement,andcosts.JGenInternMed2007;22(suppl3):391-5.
* MenottiA,Mulder I,NissinenA,GiampaoliS,FeskensEJ,KromhoutD.Prevalenceofmorbidityandmultimorbidity inelderlymale populations and their impact on 10-year all-causemortality: the FINE study (Finland, Italy, Netherlands, Elderly). J ClinEpidemiol2001;54:680-6.
Premature death
Hospital admission
Hospital stay
Multimorbidityvs.singlechroniccondition
Prevalenceofmultimorbiditybyagegroup:overall(a)andbysex(b).ViolanC,Foguet-BoreuQ,Flores-MateoG,SalisburyC,BlomJ,etal.(2014)Prevalence,DeterminantsandPatternsofMultimorbidity inPrimaryCare:ASystematicReviewofObservationalStudies.PLoSONE9(7):e102149.doi:10.1371/journal.pone.0102149
Thirty-nine studies quantified the prevalence of multimorbidity. Overall estimatesrangedfrom12.9% inparticipantsaged18yearsandolder to95.1% inapopulationaged65yearsandolder.
Prevalenceofmultimorbidity
Violan C, Foguet-BoreuQ, Flores-MateoG, Salisbury C, Blom J, et al. (2014) Prevalence, Determinants and Patterns ofMultimorbidity inPrimaryCare:ASystematicReviewofObservationalStudies.PLoSONE9(7):e102149.doi:10.1371/journal.pone.0102149
FabbriE,ZoliM,Gonzalez-FreireM,SaliveME,StudenskiSA,FerrucciL.AgingandMultimorbidity:NewTasks,Priorities,andFrontiersforIntegratedGerontologicalandClinicalResearch.JAmMedDirAssoc.2015Aug1;16(8):640-7.
The age-related multisystem loss of reserve and function, rooted in the biologicaldeterminants of the agingprocess, is associatedwith increased susceptibility for chronicdiseases,which becomes clinically evident asmultimorbiditywhen a certain threshold ofimpairmenthasbeenreached.
Riskfactorsformultimorbidity
WikströmK,LindströmJ,HaraldK,PeltonenM,LaatikainenT.Clinicalandlifestyle-relatedriskfactorsforincidentmultimorbidity:10-yearfollow-upofFinnishpopulation-basedcohorts1982-2012.EurJInternMed.2015Apr;26(3):211-6.
Disease–freepopulation
Smoking Physicalinactivity
Bodymassindex
Men
Systolicbloodpressure
Loweducation
Relationshipbetweenmultimorbidityandhealthcarecosts
Zulman DM, Pal Chee C, Wagner TH, Yoon J, Cohen DM, Holmes TH, Ritchie C, Asch SM. Multimorbidity and healthcare utilisation among high-cost patients in the US Veterans Affairs Health Care System. BMJ Open. 2015 Apr 16;5(4):e007771. doi: 10.1136/bmjopen-2015-007771.
* FortinM,LapointeL,HudonC,VanasseA,NtetuAL,MaltaisD.Multimorbidityandqualityoflifeinprimarycare:asystematicreview.HealthQualLifeOutcomes2004;2:51.
* Townsend A, Hunt K, Wyke S. Managing multiple morbidity in mid-life: a qualitative study of attitudes to drug use.BMJ2003;327:837.
* FortinM,BravoG,HudonC,VanasseA,LapointeL.Prevalenceofmultimorbidityamongadultsseeninfamilypractice.AnnFamMed2005;3:223-8.
Multimorbidicpatients
Despite the increasing numbers of patientswith two ormorechronic conditions, or multimorbidity, the delivery of care isusuallybuiltaroundsinglediseases.
Lossofphysical
functioningDepression
Multipledrugs+difficulties
withadherence
Poorerqualityoflife
Drugtoxic&harmful
Drugtoxicbutbeneficial
DrugNOTtoxic&beneficial
DrugNOTtoxic&NOTbeneficial
Patients
SameDiagnosisSamePrescription
Boyd CM, Darer J, Boult C, Fried LP, Boult L, et al. (2005) Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance. JAMA 294: 716–724
MultimorbidityandpolypharmacyBreakdownofpercentageofpatientsintheadultpopulationreceivingaparticularnumberofregularmedicineswithatleastoneissueinthepreviousyear,byage(a)andnumberofconditions(b)
PayneRA,AveryAJ,DuerdenM,SaundersCL,SimpsonCR,AbelGA.PrevalenceofpolypharmacyinaScottishprimarycarepopulation.EurJClinPharmacol.2014May;70(5):575-81.
Whataretheopportunities?
Shifting theparadigm fromvertical/mono-morbid interventionsto comorbidity and multimorbidity approaches enhanceseffectivenessandefficiencyofhumanresourcesutilization.
Multi-morbidity
Condition
Condition Condition
Condition
Human resources
Interventionelement
Studies
Professional
• Educationortrainingofcarecoordinators Boult,Katon,Sommers
Financial
Patient
• Selfmanagementsupportandpatienteducation Eakin*,Boult,Katon,Lorig*,Hochhalter*
• Peersupport Lorig
Organisational
Provider
• Carecoordinationormanagement Bognor*,Boult*,Katon*,Sommers
• Enhancedmultidisciplinaryteam Hogg*,Katon,Krska*,Sommers*
Patient:
• Individualcareplans Bognor,Boult,Hogg,Katon,Krska,Sommers
Structural:
• Structuredvisits Eakin,Bognor,Boult,Hogg,Katon,Krska
• Structuredtelephonecontact Bognor,Eakin,Hochhalter,Hogg
*Nostudiesreportedonthiselement.SmithSM,SoubhiH,FortinM,HudonC,O'DowdT.Managingpatientswithmultimorbidity:systematicreviewofinterventionsinprimarycareandcommunitysettings.BMJ.2012Sep3;345:e5205.doi:10.1136/bmj.e5205.Review
Differentapproachesformultimorbidityguidelines
Katrin Uhlig, Bruce Leff, David Kent and all. A Framework for Crafting Clinical Practice Guidelines that are Relevant to the Care and Management of People with Multimorbidity. J Gen Intern Med. 2014 Apr; 29(4): 670–679.
JointActiononChronicDiseasesandPromotingHealthyAgeingacrosstheLifeCycle(JA-
Chrodis)*
* This presentation arises from the Joint Action addressingchronic diseases and healthy ageing across the life cycle (JA-CHRODIS),whichhasreceivedfundingfromtheEuropeanUnion,undertheframeworkoftheHealthProgramme(2008-2013).
