Unraveling Multimorbidity: Challenges, Impacts & Solutions

1. Royal College of Surgeons in IrelandColáiste Ríoga na Máinleá in Éirinn Chronic Disease - what happens when they come in multiples? Susan Smith

2. Overview: Multimorbidity • Background • Why important • Impact • Research programme • Policy and healthcare delivery

3. Academic general practice grounded in clinical practice Chronic disease research: How can we improve outcomes? • Organisational approaches • DiSC, Sphere studies • Patient oriented interventions • Family diabetes study, Peer support study • Multimorbidity

4. Clinical case • 59 year old woman • Living alone • IHD; Depression; Neurological condition; Arthritis • Multiple medications • Presents with pain in her right shoulder

5. Clinical Reality “Just remember Dr Marshall, my life is like a swimming pool full of sewage and your job is to push me up into the shallow end.” Martin Marshall, McKenzie Lecture, 2010

6. Multimorbidity • Two or more chronic conditions • Ireland: • 66%, aged > 50, in GP setting • Not just older people • MM aged 45-64, GMS eligible: 7.5 meds; 11 GP visits per year

7. Impact • Higher rates mortality, medicines use, health service use, hospital admissions, psychological problems such as depression and anxiety • Poorer quality of life and physical functioning

8. Impact: costs • Costs in Ireland five times higher for patients with four or more conditions. Have average: • 11 GP visits per year • 3 OPD visits • 3.5 admissions • Reducing costs: • ‘Million dollar patients’ Cost savings?? • Reducing avoidable complications for people with chronic disease by 10% could save ??

9. Impact: costs • ‘Million dollar patients’ • 3,800 (approx) in USA in 2010 • Savings at most $3.8 billion?? vs • Reducing avoidable complications for people with chronic disease by 10% could save $40 billion

10. Challenges • Patients • Medications, physical functioning • Concept of treatment burden • Healthcare providers • Lack of time • Uncertainty and poor evidence base

11. Related issues • Overlap with frailty in older people • Link with socioeconomic deprivation • Men in most deprived group die 18 years earlier • Develop multimorbidity earlier • Inverse care law

13. Multimorbidity • Vulnerable patients within this group • Multiple medicines • High risk emergency admission • High service use and costs • Lack social support • Need cost effective intervention to improve outcomes • How to identify those in need of intervention (before it is too late)?

14. Research Programme

15. Cochrane review • Qualitative study with GPs and pharmacists • Impact of multimorbidity: • Chronic respiratory disease • Diabetes • Exploratory trial 1 • Exploratory trial 2 • Proposed cohort study and RCT Preclinical phase: Theory Phase II: Exploratory trial Phase III: Definitive RCT Phase I: Modelling Continuum of increasing evidence

16. Qualitative study of experiences’ of GPs and pharmacists managing multimorbidity • Focus groups with GPs and pharmacists • Themes • Link to multiple medicines and ageing • Health systems issues relating to lack to time, interprofessional communication difficulties, and fragmentation of care • Individual issues relating to professional roles, clinical uncertainty, and avoidance • Patient issues: ‘Not all need intervention’

17. Qualitative study of experiences’ of GPs and pharmacists managing multimorbidity • Idea of ‘Pandora’s box’ • Limited time • Coping strategies “Like eating an elephant, bite off one chunk at a time”

19. Cochrane review • Qualitative study with GPs and pharmacists • Impact of multimorbidity: • Chronic respiratory disease • Diabetes • Exploratory trial 1 • Exploratory trial 2 • Proposed cohort study and RCT Preclinical phase: Theory Phase II: Exploratory trial Phase III: Definitive RCT Phase I: Modelling Continuum of increasing evidence

20. Impact on chronic disease: Chronic Respiratory Disease (CRD) • Cross sectional study in three Dublin general practices • Results • 16,946 patients in total and 3.9% CRD • 60% of these had multimorbidity • Multimorbidity associated with increasing age and low socio-economic status • Increased consultation rates and numbers medicines

21. Impact on chronic disease: Diabetes • 424 patients with type 2 diabetes • Results • 90% two or more conditions • 25% had five or more chronic conditions • 189 conditions • Mismatch between self-report and chart review

22. Cochrane review • Qualitative study with GPs and pharmacists • Impact of multimorbidity: • Chronic respiratory disease • Diabetes • Chronic ills of ageing • Exploratory trial 1 • Exploratory trial 2 • Proposed cohort study and RCT Preclinical phase: Theory Phase II: Exploratory trial Phase III: Definitive RCT Phase I: Modelling Continuum of increasing evidence

23. Exploratory trial 1 • 20 patients with Chronic respiratory disease plus 2 other conditions; Age 40-75 • Intervention: 1. GP reports 2. Occupational therapy (OT) assessments and treatment if indicated

24. Exploratory trial 1 • Results: • 8/20 needed OT • OT group had significant improvements but intervention intensive+ • High levels depression and anxiety • GP reports ineffective

25. Exploratory trial 2 • 30 patients with 2 or more chronic conditions; >40, recruited prospectively by GP • Intervention • Six week, group based, OT-led with some physiotherapy and medicines management • Significant improvements in OT and psychosocial outcomes

27. Exploratory trial 1 • Exploratory trial 2 • Cohort study and proposed RCT • Cochrane review • Qualitative exploration of views of GPs and pharmacists • Impact of multimorbidity in diabetes and chronic respiratory disease Preclinical phase: Theory Phase II: Exploratory trial Phase III: Definitive RCT Phase I: Modelling Continuum of increasing evidence

28. Cohort study • 800 patient over aged 70 with focus on admissions • Identifying patients with multimorbidity at increased risk hospital admission • Risk score • Interviews with patients and their families who have experienced recent admission exploring triggers and potential preventable measures

29. Proposed randomised controlled trial • Complex intervention to improve outcomes for vulnerable patients with multimorbidity • Participants • MM plus recent admission • Intervention: • OT groups, case management and medication review • Outcomes • Readmission, self-efficacy, quality of life

30. Current HSE policy and multimorbidity? • Chronic disease management • Integrated care • Multidisciplinary care • Support for self-care Single conditions

31. Policy choices • Support generalist approach • Medicines management • Focus on relevant interventions and outcomes • Target increased risk individuals • Identification and cost effective intervention • Reduce burden of care

32. http://www.bmj.com/highwire/section-pdf/9015/7/1

33. Summary • Multimorbidity important • International relevance • Link to quality of care and cost agenda • Challenges • Identifying individuals at increased risk • Delivering cost effective interventions http://www.healthtalkonline.org/

34. Acknowledgment: All patients and practices who participated in research studies Questions?

35. Additional material

36. Exploratory trial 1 • Exploratory trial 2 • Proposed cohort study and RCT • Cochrane review • Qualitative study with GPs and pharmacists • Impact of multimorbidity: • Chronic respiratory disease • Diabetes Preclinical phase: Theory Phase II: Exploratory trial Phase III: Definitive RCT Phase I: Modelling Continuum of increasing evidence

37. Cochrane review of interventions to improve outcomes for patients with multimorbidity • Ten studies; all recent randomised controlled trials • Eight included patients with a broad range of conditions though elderly; two focused on co-morbid conditions • Comparing outcomes across studies a problem • Identified types of interventions being tested

38. Cochrane review: Interventions (all had multiple elements) • Professional • Education • Organisational • Care coordinators; changes to care delivery such as introduction new team member • Patient • Patient education or support groups, individual care plans • No financial or regulatory type interventions

39. Cochrane review conclusions • Limited research to date • Focus on co-morbid conditions or multimorbidity in older patients • Results suggest may be more effective to target interventions towards risk factors or specific functional difficulties. Organisational models such as Guided Care disappointing