23rd March 2018, Volume 131 Number 1472

Elinor Millar, Anthony Dowell, Ross Lawrenson, Dee Mangin, Diana Sarfati

Multimorbidity (the coexistence of more than one long-term condition) is now the norm among those with long-term conditions, with more people living with multiple conditions than with a single one.1…

Subscriber content

The full contents of this page is only available to subscribers.

To view this content please login or subscribe

Summary

More people are now living with multimorbidity (multiple long-term conditions). Currently clinical treatment guidelines focus on the management of individual conditions, and don’t usually consider the impact of combining multiple guidelines for someone with multiple conditions. This may lead to interactions between treatments and often leads to a burdensome treatment regime for patients. Clinical guidelines could be improved to better support clinicians to provide care for people with multimorbidity.

Abstract

More people now live with multimorbidity than with a single long-term condition. Despite this, clinical guidelines remain focused on the management of individual conditions. When the treatment recommendations from multiple different disease-specific guidelines are combined for one individual it frequently leads to interactions between treatments, along with a high burden of treatment for patients. It is also recognised that people with multimorbidity are often excluded from the trials that generate the underlying evidence for these guidelines, and that treatment goals from guidelines often fail to align with patient goals. This viewpoint discusses the main issues with applying disease-specific guidelines to individuals with multiple long-term conditions, and presents a set of eight recommendations to improve care for people with multimorbidity in New Zealand.

Author Information

Elinor Millar, Research Fellow, Department of Public Health, University of Otago, Wellington;
Tony Dowell, Professor, Department of Primary Health Care and General Practice, University of Otago, Wellington; Ross Lawrenson, Professor, University of Waikato, Hamilton;
Dee Mangin, Professor, Department of Family Medicine, McMaster University, Canada;
Diana Sarfati, Professor, Department of Public Health, University of Otago, Wellington.

Acknowledgements

With thanks to the wider multimorbidity research team for their work that helped shape this viewpoint. 

Correspondence

Dr Elinor Millar, Department of Public Health, University of Otago, PO Box 7343, Wellington.

Correspondence Email

elinor.millar@otago.ac.nz

Competing Interests

Dr Millar, Dr Dowell, Dr Mangin and Dr Sarfati report grants from Health Research Council, during the conduct of the study. Professor Lawrenson is both an employee of the University of Waikato and Waikato District Health Board.

References

  1. Barnett K, Mercer SW, Norbury M, et al. 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
  2. Walker AE. Multiple chronic diseases and quality of life: patterns emerging from a large national sample, Australia. Chronic Illn 2007; 3(3):202–18. doi: 10.1177/1742395307081504
  3. Salisbury C, Johnson L, Purdy S, et al. 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
  4. Ministry of Health. Health Loss in New Zealand: A report from the New Zealand Burden of Diseases, Injuries and Risk Factors Study, 2006–2016. Wellington: Ministry of Health, 2013.
  5. Banerjee S. Multimorbidity: older adults need health care that can count past one. Lancet 2014; 385(9968):587–89. doi: 10.1016/S0140-6736(14)61596-8
  6. Boyd CM, Darer J, Boult C, et al. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance. JAMA 2005; 294(6):716–24.
  7. Austad B, Hetlevik I, Mjølstad BP, et al. General practitioners’ experiences with multiple clinical guidelines: A qualitative study from Norway. Qual Prim Care 2015; 23(2):70–7.
  8. Stokes T, Tumilty E, Doolan-Noble F, et al. Multimorbidity, clinical decision making and health care delivery in New Zealand Primary care: a qualitative study. BMC Fam Pract 2017; 18(1):51. doi: 10.1186/s12875-017-0622-4
  9. Dumbreck S, Flynn A, Nairn M, et al. Drug-disease and drug-drug interactions: systematic examination of recommendations in 12 UK national clinical guidelines. BMJ : British Medical Journal 2015; 350 doi: 10.1136/bmj.h949
  10. Fried TR, Tinetti ME, Iannone L. Primary care clinicians’ experiences with treatment decision making for older persons with multiple conditions. Arch Intern Med 2011; 171(1):75–80. doi: 10.1001/archinternmed.2010.318
  11. Sinnott C, Mc Hugh S, Browne J, et al. GPs’ perspectives on the management of patients with multimorbidity: systematic review and synthesis of qualitative research. BMJ Open 2013; 3(9) doi: 10.1136/bmjopen-2013-003610
  12. May C, Montori VM, Mair FS. We need minimally disruptive medicine. BMJ 2009; 339 doi: 10.1136/bmj.b2803
  13. Rosbach M, Andersen JS. Patient-experienced burden of treatment in patients with multimorbidity – A systematic review of qualitative data. PLoS One 2017; 12(6):e0179916. doi: 10.1371/journal.pone.0179916
  14. Jowsey T, McRae IS, Valderas JM, et al. Time’s up. Descriptive epidemiology of multi-morbidity and time spent on health related activity by older Australians: a time use survey. PLoS One 2013; 8(4):e59379. doi: 10.1371/journal.pone.0059379 [published Online First: 2013/04/06]
  15. Buffel du Vaure C, Ravaud P, Baron G, et al. Potential workload in applying clinical practice guidelines for patients with chronic conditions and multimorbidity: a systematic analysis. BMJ Open 2016;6(3) doi: 10.1136/bmjopen-2015-010119
  16. Mishra SI, Gioia D, Childress S, et al. Adherence to medication regimens among low-income patients with multiple comorbid chronic conditions. Health Soc Work 2011; 36(4):249–58. doi: 10.1093/hsw/36.4.249
  17. Townsend A, Hunt K, Wyke S. Managing multiple morbidity in mid-life: a qualitative study of attitudes to drug use. BMJ 2003; 327(7419):837. doi: 10.1136/bmj.327.7419.837
  18. Kuluski K, Gill A, Naganathan G, et al. A qualitative descriptive study on the alignment of care goals between older persons with multi-morbidities, their family physicians and informal caregivers. BMC Fam Pract 2013; 14:133. doi: 10.1186/1471-2296-14-133
  19. Morris RL, Sanders C, Kennedy AP, et al. Shifting priorities in multimorbidity: a longitudinal qualitative study of patient’s prioritization of multiple conditions. Chronic Illn 2011; 7(2):147–61. doi: 10.1177/1742395310393365
  20. Mangin D SG, Bismah V, Risdon C. Making patient preferences visible in healthcare: a systematic review of tools to assess patient treatment priorities and preferences in the context of multimorbidity. BMJ Open 2016 doi: 10.1136/bmjopen-2015-010903
  21. Boyd CM, Vollenweider D, Puhan MA. Informing Evidence-Based Decision-Making for Patients with Comorbidity: Availability of Necessary Information in Clinical Trials for Chronic Diseases. PLoS One 2012; 7(8):e41601. doi: 10.1371/journal.pone.0041601
  22. Fortin M, Dionne J, Pinho G, et al. Randomized Controlled Trials: Do They Have External Validity for Patients With Multiple Comorbidities? Ann Fam Med 2006; 4(2):104–08. doi: 10.1370/afm.516
  23. Jadad AR, To MJ, Emara M, et al. Consideration of multiple chronic diseases in randomized controlled trials. JAMA 2011; 306(24):2670–72. doi: 10.1001/jama.2011.1886
  24. Zulman DM, Sussman JB, Chen X, et al. Examining the Evidence: A Systematic Review of the Inclusion and Analysis of Older Adults in Randomized Controlled Trials. J Gen Intern Med 2011; 26(7):783–90. doi: 10.1007/s11606-010-1629-x
  25. Van Spall HC, Toren A, Kiss A, et al. Eligibility criteria of randomized controlled trials published in high-impact general medical journals: A systematic sampling review. JAMA 2007; 297(11):1233–40. doi: 10.1001/jama.297.11.1233
  26. Kendrick T, Hegarty K, Glasziou P. Interpreting research findings to guide treatment in practice. BMJ 2008; 337 doi: 10.1136/bmj.a1499
  27. Steel N, Abdelhamid A, Stokes T, et al. A review of clinical practice guidelines found that they were often based on evidence of uncertain relevance to primary care patients(). J Clin Epidemiol 2014; 67(11):1251–57. doi: 10.1016/j.jclinepi.2014.05.020
  28. Huang ES, Zhang Q, Gandra N, et al. The effect of comorbid illness and functional status on the expected benefits of intensive glucose control in older patients with type 2 diabetes: A decision analysis. Ann Intern Med 2008; 149(1):11–19. doi: 10.7326/0003-4819-149-1-200807010-00005
  29. Greenfield S, Billimek J, Pellegrini F, et al. Comorbidity affects the relationship between glycemic control and cardiovascular outcomes in diabetes: A cohort study. Ann Intern Med 2009; 151(12):854–60. doi: 10.7326/0003-4819-151-12-200912150-00005
  30. Kent DM, Hayward RA. Limitations of applying summary results of clinical trials to individual patients: The need for risk stratification. JAMA 2007; 298(10):1209–12. doi: 10.1001/jama.298.10.1209
  31. Kravitz RL, Duan N, Braslow J. Evidence-Based Medicine, Heterogeneity of Treatment Effects, and the Trouble with Averages. Milbank Q 2004; 82(4):661–87. doi: 10.1111/j.0887-378X.2004.00327.x
  32. Wallace E, Salisbury C, Guthrie B, et al. Managing patients with multimorbidity in primary care. BMJ : British Medical Journal 2015;350 doi: 10.1136/bmj.h176
  33. Hughes LD, McMurdo MET, Guthrie B. Guidelines for people not for diseases: the challenges of applying UK clinical guidelines to people with multimorbidity. Age Ageing 2013; 42(1):62–69. doi: 10.1093/ageing/afs100
  34. Steinman MA, Sudore RL, Peterson CA, et al. Influence of Patient Age and Comorbid Burden on Clinician Attitudes Toward Heart Failure Guidelines. Am J Geriatr Pharmacother 2012; 10(3):211–18. doi: http://doi.org/10.1016/j.amjopharm.2012.04.003
  35. Uhlig K, Leff B, Kent D, et al. A Framework for Crafting Clinical Practice Guidelines that are Relevant to the Care and Management of People with Multimorbidity. J Gen Intern Med 2014; 29(4):670–79. doi: 10.1007/s11606-013-2659-y
  36. Treadwell J. Coping with complexity: working beyond the guidelines for patients with multimorbidities. J Comorb 2015; 5(1):11–14.
  37. Guthrie B, Payne K, Alderson P, et al. Adapting clinical guidelines to take account of multimorbidity. Br Med J 2012; 345(oct04):e6341–e41.
  38. Turner EH, Matthews AM, Linardatos E, et al. Selective publication of antidepressant trials and its influence on apparent efficacy. N Engl J Med 2008; 358(3):252–60. doi: 10.1056/NEJMsa065779
  39. Boyd CM, Kent DM. Evidence-Based Medicine and the Hard Problem of Multimorbidity. J Gen Intern Med 2014; 29(4):552–53. doi: 10.1007/s11606-013-2658-z
  40. Blozik E, van den Bussche H, Gurtner F, et al. Epidemiological strategies for adapting clinical practice guidelines to the needs of multimorbid patients. BMC Health Serv Res 2013; 13(1):352. doi: 10.1186/1472-6963-13-352
  41. Weiss CO, Varadhan R, Puhan MA, et al. Multimorbidity and Evidence Generation. J Gen Intern Med 2014; 29(4):653–60. doi: 10.1007/s11606-013-2660-5
  42. Sarfati D, Koczwara B, Jackson C. The impact of comorbidity on cancer and its treatment. CA Cancer J Clin 2016; 66(4):337–50.
  43. Levit LA, Balogh E, Nass SJ, et al. Delivering high-quality cancer care: charting a new course for a system in crisis: National Academies Press Washington, DC 2013.
  44. Allan GM, Kraut R, Crawshay A, et al. Contributors to primary care guidelines: What are their professions and how many of them have conflicts of interest? Can Fam Physician 2015; 61(1):52–58.
  45. McGeoch G, Anderson I, Gibson J, et al. Consensus pathways: evidence into practice. NZ Med J 2015; 128(1408):86–96.
  46. McGeoch G, McGeoch P, Shand B. Is HealthPathways effective? An online survey of hospital clinicians, general practitioners and practice nurses. NZ Med J 2015; 128(1408):2010–19.
  47. Braithwaite RS, Fiellin D, Justice AC. The Payoff Time: A Flexible Framework to Help Clinicians Decide When Patients With Comorbid Disease are not Likely to Benefit From Practice Guidelines. Med Care 2009; 47(6):610–17. doi: 10.1097/MLR.0b013e31819748d5
  48. Flinders University. The Flinders Program 2016 [Available from: http://flindersprogram.com/ accessed 18-12-2017 2017.
  49. Lorig KR, Sobel DS, Ritter PL, et al. Effect of a self-management program on patients with chronic disease. Effective clinical practice: ECP 2001; 4(6):256–62.
  50. Department of Health. The expert patient: a new approach to chronic disease management for the twenty-first century. Clin Med (Northfield Il) 2002; 2(3):227–29.
  51. Man M-S, Chaplin K, Mann C, et al. Improving the management of multimorbidity in general practice: protocol of a cluster randomised controlled trial (The 3D Study). BMJ Open 2016; 6(4) doi: 10.1136/bmjopen-2016-011261
  52. National Institute for Health and Care Excellence. Multimorbidity: clinical assessment and managment. NICE guideline, 2016.
  53. Upshur REG. Do Clinical Guidelines Still Make Sense? No. Ann Fam Med 2014; 12(3):202–03. doi: 10.1370/afm.1654
  54. Sinnige J, Braspenning J, Schellevis F, et al. The Prevalence of Disease Clusters in Older Adults with Multiple Chronic Diseases – A Systematic Literature Review. PLoS One 2013; 8(11):e79641. doi: 10.1371/journal.pone.0079641
  55. Cowie L, Morgan M, White P, et al. Experience of continuity of care of patients with multiple long-term conditions in England. J Health Serv Res Policy 2009; 14(2):82–87. doi: 10.1258/jhsrp.2009.008111
  56. Lugtenberg M, Burgers JS, Clancy C, et al. Current Guidelines Have Limited Applicability to Patients with Comorbid Conditions: A Systematic Analysis of Evidence-Based Guidelines. PLoS One 2011;6(10):e25987. doi: 10.1371/journal.pone.0025987

Download

The downloadable PDF version of this article is only available to subscribers.

To view this content please login or subscribe