How should health policy respond to the growing challenge of multimorbidity? We need patient-centred care, with more emphasis on generalist rather than specialist care and better integration between general practice, hospitals and social care PolicyBristol – influencing policy through world-class research Policy Report 39: October 2018 Summary There is growing awareness internationally of the increasing number of people living with multiple long-term health condition, known as multimorbidity. Health services, including the NHS, need to adapt to address this challenge. People with multimorbidity are more likely to experience poor quality of life and poor physical and mental health. They use both general practice and hospital services far more than often than the general population. Treatment itself can be an additional burden if they need to take numerous prescribed drugs and attend frequent health care appointments. More and more people are living with multimorbidity. A major driver of this is that people are living longer. Multimorbidity poses major challenges for health care systems around the world, which are largely designed to manage individual diseases and episodes of illness. These need to be re-orientated towards providing care for people who have several long-standing health conditions at the same time, many of which are manageable but not curable. There will need to be a new relationship between patients and health care professionals, which will engage patients more in managing their health conditions themselves. Health care services need to invest in better generalist care and become less focussed on care for single diseases, and closer integration of health and social care will be necessary. What is multimorbidity? Multimorbidity is usually defined as the existence of two or more long term health conditions in the same individual.1 Many of these conditions are not curable but can be managed to help reduce adverse symptoms, slow deterioration, and enable people to adapt their lives to cope better. Managing long-term conditions well requires actions from both the patient and the health care system. How common is multimorbidity? Determining the number of people affected is difficult because it depends on the number of health conditions included in the definition of multimorbidity. However it is clear that the prevalence of multimorbidity increases with age and is higher in less affluent areas.2 A large Scottish study, examining 40 significant long-term health conditions, found that two out of three people aged 65 years or over had two or more of these conditions, rising to more than eight out of ten of those aged over 85.3 Multimorbidity is therefore the norm for older people in developed countries such as the UK. 100 90 80 70 60 50 40 30 20 10 0 Patients (%) Age Group (years) 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+ 0 1 2 3 4 5 6 7 8+ 4 5 6 7 8+ Number of conditions Zero conditions 1 condition 2 3 Figure 1: Number of chronic disorders by age-group. (adapted from Barnett et al 2012)3 However, multimorbidity is not just a problem of the elderly. Because there are more middle-aged than elderly people in the population, there are actually more people with multimorbidity aged under rather than over 65 years old.4 The number of people in the population with long-term health conditions such as diabetes, heart disease and dementia is rising for several reasons. These include the ageing population, increases in obesity, and improvements in medical care so that people survive longer with conditions that in the past would have been fatal. As the prevalence of most long-term conditions increases, so does the number of people living with multimorbidity. Between 2015 and 2035 the number of older people with four or more long term conditions will double, and a third of these people will have mental health problems such as depression, or dementia or cognitive impairment. 4 1 The Academy of Medical Sciences. Multimorbidity: a priority for global health research. London; 2018 April 2018. 2 Violan C, Foguet-Boreu Q, Flores-Mateo G, Salisbury C, Blom J, Freitag M, et al. Prevalence, determinants and patterns of multimorbidity in primary care: a systematic review of observational studies. PLoS One 2014; 9(7): e102149. DOI: 10.1371/journal.pone.0102149 3 Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet 2012; 380(9836): 37-43. DOI: 10.1016/S0140-6736(12)60240-2 4 Kingston A, Robinson L, Booth H, Knapp M, Jagger C for the MODEM project. Projections of multi-morbidity in the older population in England to 2035: estimates from the Population Ageing and Care Simulation (PACSim) model, Age and Ageing, 47 (3) 374–380. DOI: 10.1093/ageing/afx201 PolicyBristol – influencing policy through world-class research Policy Report 39: October 2018 Why is multimorbidity a problem for patients? Compared with people with single health problems, people with multimorbidity are more likely to have a reduced quality of life, impaired function, worse general health and an increased risk of premature death. People with multiple physical health problems are more likely have to poor mental health, and this in turn makes them less likely to manage their physical health problems well. People with multimorbidity are often prescribed large numbers of drugs, expected to make many changes to life-style and to attend numerous health care appointments. Therefore, treatment itself can be a major burden for patients, in addition to the burden of being ill. Because patients with multimorbidity receive care from a number of different organisations and individual clinicians they often experience poor continuity of care. They can feel that their care is not joined-up since different clinicians often only focus on one aspect of their problems and no-one treats them as a ‘whole person’. That is because care is often disease-focused rather than patient-centred. “I always feel you’re better going to the same doctor to see him about yourself, instead of explaining to the next doctor or another doctor which has not been seeing you about it.”1 What is the problem for the NHS? People with multimorbidity account for a disproportionately high number of consultations in general practice and their treatment is expensive because they are likely to be prescribed numerous drugs. 10 8 6 6 4 2 14 12 18-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ 10 8 6 6 4 14 12 Annual consultation rate multimorbid not multimorbid Figure 2 Figure 2: Annual general practice consultation rate by age and multimorbidity status2 People with multimorbidity also have high rates of emergency hospital admissions and attendance at outpatient appointments. In one study, only 10% of patients had four or more physical health conditions, but these patients accounted for more than a third of all unplanned admissions to hospital and almost half of potentially preventable unplanned admissions.3 0 500 400 300 200 100 600 0 1 2 3 4 5 6 7 8 9 Annual admission rate per 1000 people Number of conditions Potentially preventable admissions Other emergency admissions 10+ Figure 3 31 51 74 115 151 200 242 318 342 20 479 5 9 14 21 34 47 64 85 100 3 151 Figure 3: Rates of hospital admissions in patients with multimorbidity3 1 Salisbury C, Man MS, Bower P, Guthrie B, Chaplin K, Gaunt DM, et al. Management of multimorbidity using a patient-centred care model: a pragmatic cluster-randomised trial of the 3D approach. Lancet. 2018. 392:41-50. DOI: 10.1016/S0140-6736(18)31308-4 2 Salisbury C, Johnson LR, Purdy S, Valderas JM, Montgomery AA. Epidemiology and impact of multimorbidity in primary care: a retrospective cohort study. Br J Gen Pract. 2011;61(582):e12-e21. DOI: 10.3399/bjgp11X548929 3 Payne R.A. Abel G.A Guthrie B., Mercer S.W. The effect of physical multimorbidity, mental health conditions and socioeconomic deprivation on unplanned admissions to hospital: a retrospective cohort study CMAJ Feb 2013, cmaj.121349; DOI: 10.1503/cmaj.121349 PolicyBristol – influencing policy through world-class research Policy Report 39: October 2018 There is an almost exponential relationship between the number of health conditions affecting an individual and their use of health care resources.1 In the US, it is estimated that people with multimorbidity account for more than two-thirds of all health care spending. The economic impact of increasing multimorbidity in the population is therefore very substantial. We need to consider new ways of providing health care which more effectively support self-care, reduce inefficiencies and reduce reliance on expensive hospital care. Medicine in all developed countries is organised around specialities which are defined by disease or body system. The care experienced by patients in hospital is to some extent dictated by which speciality deals with the initial cause of admission. But since most hospital admissions involve people with long-term conditions, and most of these patients have multimorbidity, better generalist care is needed to ensure appropriate care, and a timely and well co-ordinated handover to care outside hospital. Similarly, specialists in out-patient departments understandably tend to focus on problems within their domain of expertise, but this can mean that a patient’s other problems get less attention or that they have to be referred between different specialists. “There is a weakness on co-morbidity. The computer can’t cope with two concepts in one bite. I’m not worried about it, but what it means in practice is that a patient with co-morbidity gets maybe three or four letters a year as opposed to one letter a year. Because they get the letter for heart disease and then they get the letter for asthma, then they get the letter for diabetes” (GP 09)2 The focus on single diseases impacts general practice as well as hospitals. Within the UK, the care of long term conditions is increasingly organised around care pathways, protocols and treatment guidelines for each specific disease. However, this approach is problematic for people with multimorbidity. “so you have a guy with ischaemic heart disease who automatically has to go on five agents and then he’s got diabetes, he’s got another three agents and if you were to take each of the conditions, not necessarily diseases, maybe just lipidaemia or whatever, and put them on the best management protocol for that particular condition, you know, they’re straight away on 20 different agents, and if you stop any of those then you’re not following the guidelines for each of those.” (GP6)3 Most treatment guidelines have been developed for less complex people with single health conditions and their recommendations may not be applicable to people with multimorbidity. If health professionals try to follow several different disease-specific protocols for the same patient, this may lead to advice which is burdensome, contradictory or inappropriate in the light of the patient’s other conditions. “Somebody with diabetes, you encourage them to exercise, [but] maybe if they’ve got a respiratory condition, it stops them from doing that. So sometimes your advice conflicts, you know, when you’ve got multiple problems.” PN 2 (27yrs qualified: Practice Nurse)4 1 Lehnert T, et al. (2011). Health Care Utilization and Costs of Elderly Persons with Multiple Chronic Conditions. Medical Care Research and Review 68(4), 387–420. DOI: 10.1177/1077558711399580 2 Peter Bower, Wendy Macdonald, Elaine Harkness, Linda Gask, Tony Kendrick, Jose M Valderas, Chris Dickens, Tom Blakeman, Bonnie Sibbald; Multimorbidity, service organization and clinical decision making in primary care: a qualitative study, Family Practice, Volume 28, Issue 5, 1 October 2011, Pages 579–587. DOI: 10.1093/fampra/cmr018 3 Smith SM, O’Kelly S, O’Dowd T. GPs’ and pharmacists’ experiences of managing multimorbidity: a ‘Pandora’s box’. Br J Gen Pract. 2010. 60(576):285-94. DOI: 10.3399/bjgp10X514756 4 Coventry PA, Fisher L, Kenning C, Bee P, Bower P. Capacity, responsibility, and motivation: a critical qualitative evaluation of patient and practitioner views about barriers to self-management in people with multimorbidity. ©BMC Health Serv Res. Oct 31 2014;14(1):536. DOI: 10.1186/s12913-014-0536-y Published under licence CC BY 2.0. PolicyBristol – influencing policy through world-class research Policy Report 39: October 2018 What are the solutions? Several national and international bodies have recognised these problems and have published reports about multimorbidity (see Further Reading). Although these reports have different purposes and audiences, there is a lot of overlap in their recommendations. Summary of recommendations from major reports 1 National Guideline Centre. Multimorbidity: clinical assessment and management. London: National Institute for Health and Care Excellence; 2016. Think carefully about the risks and benefits, for people with multimorbidity, of individual treatments recommended in guidance for single health conditions. Discuss this with the patient alongside their preferences for care and treatment.1