Multimorbidity Is it really something new?

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2 Multimorbidity Is it really something new? Dr Rokas Navickas Consultant cardiologist Vilnius University Hospital Santariskiu Clinic Multimorbidity WP co-leader, CHRODIS Joint Action Programme European Health Forum Gastein

3 What s the challenge?

4 Multimorbidity vs. single chronic condition Prematurely death Hospital admission Hospital stays Vogeli C, Shields AE, Lee TA, Gibson TB, Marder WD, Weiss KB, et al. Multiple chronic conditions: prevalence, health consequences, and implications for quality, care management, and costs. J Gen Intern Med 2007;22(suppl 3): Menotti A, Mulder I, Nissinen A, Giampaoli S, Feskens EJ, Kromhout D. Prevalence of morbidity and multimorbidity in elderly male populations and their impact on 10-year all-cause mortality: the FINE study (Finland, Italy, Netherlands, Elderly). J Clin Epidemiol2001;54:680-6.

5 Prevalence of multimorbidity Thirty-nine studies measured the prevalence of multimorbidity. Overall estimates ranged from 12.9% in participants aged 18 years and older to 95.1% in a population aged 65 years and older. Prevalence of multimorbidity by age group: overall (a) and by sex (b). Violan C, Foguet-Boreu Q, Flores-Mateo G, Salisbury C, Blom J, et al. (2014) Prevalence, Determinants and Patterns of Multimorbidity in Primary Care: A Systematic Review of Observational Studies. PLoS ONE 9(7): e doi: /journal.pone

6 Violan C, Foguet-Boreu Q, Flores-Mateo G, Salisbury C, Blom J, et al. (2014) Prevalence, Determinants and Patterns of Multimorbidity in Primary Care: A Systematic Review of Observational Studies. PLoS ONE 9(7): e doi: /journal.pone

7 The age-related multisystem loss of reserve and function, rooted in the biological determinants of the aging process, is associated with increased susceptibility for chronic diseases, which becomes clinically evident as multimorbidity when a certain threshold of impairment has been a reached. Fabbri E, Zoli M, Gonzalez-Freire M, Salive ME, Studenski SA, Ferrucci L. Aging and Multimorbidity: New Tasks, Priorities, and Frontiers for Integrated Gerontological and Clinical Research. J Am Med Dir Assoc Aug 1;16(8):640-7.

8 Risk factors for multimorbidity Disease free population Men smoking Physical inactivity Body mass index Systolic blood pressure Low education Wikström K, Lindström J, Harald K, Peltonen M, Laatikainen T. Clinical and lifestyle-related risk factors for incident multimorbidity: 10-year follow-up of Finnish population-based cohorts Eur J Intern Med Apr;26(3):211-6.

9 Relationship between multimorbidity and healthcare costs 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 Apr 16;5(4):e doi: /bmjopen

10 Multimorbidic patients Loss of physical functioning Depression Multiple drugs + difficulties with adherence Poorer quality of life Despite the increasing numbers of patients with two or more chronic conditions, or multimorbidity, the delivery of care is usually built around single diseases. Fortin M, Lapointe L, Hudon C, Vanasse A, Ntetu AL, Maltais D. Multimorbidity and quality of life in primary care: a systematic review. Health Qual Life Outcomes 2004;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. Fortin M, Bravo G, Hudon C, Vanasse A, Lapointe L. Prevalence of multimorbidity among adults seen in family practice. Ann Fam Med 2005;3:223-8.

11 Patients Drug toxic & harmful Drug NOT toxic & beneficial Same Diagnosis Same Prescription Drug toxic but beneficial Drug NOT toxic & NOT beneficial 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:

12 What are the opportunities?

13 Condition Condition Condition Multimorbidity Condition Human resources Shifting the paradigm from vertical/mono-morbid interventions to comorbidity and multimorbidity approaches enhances effectiveness and efficiency of human resources utilization.

14 Intervention element Studies Professional Education or training of care coordinators Boult, Katon, Sommers Financial Patient Self management support and patient education Eakin*, Boult, Katon, Lorig*, Hochhalter* Peer support Lorig Organisational Provider Care coordination or management Bognor*, Boult*, Katon*, Sommers Enhanced multidisciplinary team Hogg*, Katon, Krska*, Sommers* Patient: Individual care plans Bognor, Boult, Hogg, Katon, Krska, Sommers Structural: Structured visits Eakin, Bognor, Boult, Hogg, Katon, Krska Structured telephone contact Bognor, Eakin, Hochhalter, Hogg *No studies reported on this element. Smith SM, Soubhi H, Fortin M, Hudon C, O'Dowd T. Managing patients with multimorbidity: systematic review of interventions in primary care and community settings. BMJ Sep 3;345:e5205. doi: /bmj.e5205. Review

15 Different approaches for multimorbidity guidelines 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 Apr; 29(4):

16 Joint Action on Chronic Diseases and Promoting Healthy Ageing across the Life Cycle (JA- Chrodis)* * This presentation arises from the Joint Action addressing chronic diseases and healthy ageing across the life cycle (JA- CHRODIS), which has received funding from the European Union, under the framework of the Health Programme ( ). Rokas.navickas@santa.lt