Management of patients with multimorbidity: the perspective of primary care
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1 Management of patients with multimorbidity: the perspective of primary care Prof. François Schellevis MD PhD NIVEL (Netherlands Institute for Health Services Research), Utrecht & Dept. General Practice & Elderly Care Medicine / Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam
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5 What I will talk about Introduction: definitions, epidemiology Relevance Management: experiences and evidence Concluding remarks
6 Comorbidity any distinct additional clinical entity that has existed or that may occur during the clinical course of a patient who has the index disease under study (Feinstein, 1970)
7 Multimorbidity the co-occurrence of multiple chronic or acute diseases and medical conditions within one person (van den Akker et al, 1996)
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9 Multimorbidity (comorbidity) multiple diseases (2 or more) in the same patient usually chronic diseases
10 Overlapping concepts Fried et al, 2004
11 Epidemiology of multimorbidity not easy to establish rates depend on e.g. - setting - measurement method - number of disease (entities) and their level of detail - age groups
12 Epidemiology of multimorbidity
13 Epidemiology of multimorbidity Rule of thumb: among people with a chronic disease 65% of the % of the 85+ suffers from multimorbidity
14 Relevance of multimorbidity Diagnostic Therapeutic Care complexity Patient s perspective
15 Relevance of multimorbidity: diagnostic (1) Mr. Smith 69 years old 3 months ago AMI (hospitalisation) good recovery, rehabilitation programme medication: beta-blocker, ASA
16 Relevance of multimorbidity: diagnostic (2) Mr. Smith s surgery visit: Tiredness Sleeping problems Concentration disturbance What are the plausible causes?
17 Relevance of multimorbidity: diagnostic (3) GPs are less inclined to diagnose a depression in patients who already suffer from a somatic chronic disease (OR = 4.2) Nuyen et al. Psychol Med 2005
18 Relevance of multimorbidity: therapeutic (1) Mrs. Johnson 79 years old medical record: osteoporosis, osteoarthritis, diabetes type II, COPD, hypertension
19 Relevance of multimorbidity: therapeutic (2) Mrs. Johnson s EBM treatment: 12 different drugs in 19 dosages at five moments a day 14 different non-pharmacological treatment advices (rest, exercise, shoes, avoid exposure to allergens) nutrition: reduce intake of Na, K, lipids, cholesterol, Mg, Ca, calories, alcohol at least 5 doctor visits per year Boyd et al. JAMA 2005
20 Relevance of multimorbidity: therapeutic (3) What is the evidence for the combined treatment of 5 diseases? How feasible is this regime? What does mrs. Johnson think about this regime? What about her quality of life?
21 Relevance of multimorbidity: care complexity (1) Diabetes mellitus patients: risk for specialized care in 1 year Outpatient Hospital DM ref ref DM DM DM + 3 or more Struijs et al. BMC Health Serv Res 2005
22 Relevance of multimorbidity: care complexity (2) Use of health care services: the more chronic diseases, the more different health care services are being used (and the more health care providers are involved) Westert et al. Eur J Publ Health 2001
23 The patient s perspective Focus groups of patients: Treatment (incl. advices) is not feasible Which caregiver is the expert? Need for information More attention for emotional impact Better coordination and communication Heijmans et al. 2003
24 A patient with multimorbidity I really thought I was going crazy. It had an enormous emotional impact. When I was also diagnosed with diabetes, I had to pay attention to what I was eating and the use of insulin, but at the same time take my pills at the right moment. It was a mess. And I was so afraid of becoming hypoglycaemic. And because of my Parkinson s disease I had trouble injecting my insulin and getting the pills in the right boxes. Heijmans et al, 2003
25 The professional s perspective Lack of evidence for medical treatment Quality of care decreased Patient unsafety Health care organisation is disease-specific Poor information management Who coordinates? Heijmans et al. 2003
26 Intermezzo Conclusions so far Multimorbidity is the rule rather than the exception among older people with a chronic disease Multimorbidity is relevant in terms of diagnostics, therapy and care complexity Both patients and professionals experience problems What does this mean for the management of multimorbid patients?
27 als/prevention-chroniccare/decision/mcc/video/index.h tml
28 Challenges for health care Focus on patients with the highest needs Existing care programs Evidence of effective programs Multimorbidity in consultations Polypharmacy
29 Multimorbidity patients: subgroups according to health care use (N=20,167) Hopman P, et al. Eur J Int Med 2016
30 Multimorbidity patients: subgroups according to health care use (N=20,167) 100% 90% 100% 100% 80% 78% 60% 40% 20% 6% 10% 9% 44% 19% 22% 26% 38% Huisartscontacten GP contacts Polyfarmacie Polypharmacy Dagopname(s) Hospital day care Ziekenhuisopname(s) Hospital stay 0% Normal (57%) High (35%) Very high (8%) Hopman P, et al. Eur J Int Med 2016
31 Multimorbidity patients: subgroups according to health care use (N=20,167) Subgroup very high use (8%): 70% women Mean age 72 years Mean number of chronic diseases 3.1 More frequent: heart failure, COPD, ischaemic heart disease, diabetes mellitus Hopman P, et al. Eur J Int Med 2016
32 Diversity in multimorbid patients: not only in medical respect Morbidity profile Care needs (incl. social domain, e.g. loneliness ) Care complexity
33 Care programs for multimorbid patients in Europe (N=128) Noordman J, van der Heide I, Hopman P, Schellevis F, Rijken M. Innovative health care approaches for patients with multi-morbidity in Europe. Utrecht: NIVEL, February Bramwell C. Don RM,. Porter I, Lloyd H, Kadam U, Rijken M, Valderas JM. Caring for people with multiple chronic conditions in the United Kingdom: policy and practices with a focus on England and Scotland.
34 Examples of care programs for multimorbid patients POTKU, Finland Clinic for Multimorbidity and Polypharmacy, Denmark Strategy for Chronic Care Valencia Region, Spain Primary aim Target group Increase patientcenteredness Patients with chronic diseases Substitution of care, from secondary to primary care Patients with chronic diseases and complex care needs Improvement of integrated care High needs-/complex patients (top 5%) Setting Primary care Diagnostic center in hospital Primary and secondary care Care model Source: ICARE4EU Teams of GPs and nurses; individual care plan Teams of medical specialists; one-day service; treatment plan for GP Collaboration between casemanagers in primary and secondary care; joint monitoring Hopman P, et al. Eur J Int Med 2016
35 Typology of multimorbidity care programmes in Europe (N=128) Mainly bottom-up and temporary initiatives Much variation in models and work-up Common feature: important role of nurses Disease specific vs. integrated programs Integrated care programs more in countries with a strong primary care Source: ICARE4EU
36 Typology of multimorbidity care programmes in Europe (N=128) 42% focus on combinations of specific diseases ( index disease and common comorbidities): diabetes mellitus, ischaemic heart disease, heart failure, hypertension, kidney disease 58% integrated care programmes, personcentred care Source: ICARE4EU
37 Differences between disease-specific and general programmes Disease specific care Promoting evidence based practice Focus on prevention, diagnostics and treatment Source: ICARE4EU Integrated care Integration of different organizations (medical/social) Involving patients and informal carers Home care, nursing care, social care Case management
38 Systematic review of care programs
39 Systematic review of care programs 19 studies (only one in Europe) mainly focusing on frail elderly large variation in type of care program positive effects (+): patient satisfaction, quality of life, functioning no effects: health care utilisation, costs
40 European Multimorbidity care model Care process Decision support Self management support Information system Local support Periodic comprehensive patient evaluation Implementation evidence-based medicine Training care providers in tailored support Elektronic health records Access to local and community services Multidisciplinary team Team training Support patients in improving their health literacy Information exchange Involve local network and attention for physical environment Individual care plan Involve patients actively in decision making Uniform coding/ classification/langua ge Psychosocial support Casemanager Involve family members and care givers Patient portals Support patients in using ehealth applications Source: JA Chrodis
41 Management of multimorbid patients in consultations
42 Management of multimorbid patients
43 Management of multimorbid patients: the Ariadne principles
44 Polypharmacy Inevitable consequence of multimorbidity Usually defined as the simultaneous chronic use of five different medications Increased risks Non-adherence Interactions Adverse effects Hospitalisation, mortality
45 Polypharmacy: inter-practice variation Sinnige et al, 2016
46 Polypharmacy: multidisciplinary guideline Clinical medication review ( expert based ) Persons > 65 years of age using five different drugs Start and Stop criteria General practitioner + pharmacist Including patient information
47 Effectiveness of medication reviews: only on drug-related problems, not on clinical outcomes
48 Conclusions (1) Focus on patients with the highest needs: More research needed to identify multimorbid patients who will profit most Existing care programs Not embedded in national policies Very heterogeneous
49 Conclusions (2) Evidence of effective programs Mainly from US studies Investment in proper evaluations necessary Multimorbidity in consultations: experts say Individual care plans Systematic approach Polypharmacy: experts say Clinical medication reviews
50 Thank you for your attention!
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