Editorial
Volume 47, No. 1-2, January-February 2018

Multimorbidity

Christopher Harrison    A Niroshan Siriwardena   
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It has been estimated that half of the patients at general practice encounters, and one-quarter of the Australian population, have two or more diagnosed chronic conditions.1 This is of concern as patients with multiple chronic conditions have been shown to have a decreased quality of life,2 higher use of health services3 and increased risk of mortality.4 Such patients are at risk of receiving fractured care, as our healthcare system is structured to provide care for single diseases, especially in the tertiary sector.

In 1970, Feinstein coined the term ‘comorbidity’ to describe ‘any distinct additional entity that has existed or may occur during the clinical course of a patient who has the index disease under study’.5 However, this concept of ‘comorbidity’ is disease-centric, and while this is a useful concept for medical specialists, it further entrenches the disease-specific structure of Australia’s healthcare system. By contrast, multimorbidity, commonly defined as the ‘co-occurrence of two or more chronic conditions within one person without defining an index chronic condition’,6 has the person, not a disease, as the focus. The concept of multimorbidity is thus more useful in a primary care setting, as the general practitioner’s (GP’s) focus is not on one particular condition, but on the holistic care of the patient.

Over the previous decade, there has been a range of incentives for GPs to manage patients’ chronic conditions; however, there is no agreed definition of what constitutes a chronic condition, let alone an agreed definition of multimorbidity.6 In this issue, Gordon et al7 outline a set of criteria for what constitutes a chronic condition. From these criteria, they provide a more extensive list of chronic conditions than the few commonly considered. They hope their definition will be used as a starting point for researchers, clinicians and policymakers to agree on a standard definition.

The care of patients with multimorbidity can be complex and overwhelming. There are few guidelines that have been developed specifically for people with multimorbidity.8 Disease-specific guidelines are often not appropriate for the care of patients with multimorbidity, as they are based on clinical trials, which rarely include patients with multiple chronic conditions.9 Rigidly following disease‑specific guidelines for all the conditions a patient with multimorbidity has can be detrimental to the patient’s health, leading to polypharmacy and care that is often contraindicated.10 Managing each condition can also create a treatment burden that is unmanageable for patients. In this issue, Leeder et al11 report the treatment burden faced by patients with multimorbidity. These patients found their medication management ‘complicated, time-consuming, inconvenient and confusing’, and the authors suggest GPs review patients’ medications with the aim of deprescribing.11

Patients with multimorbidity can be overwhelmed by the treatment burden involved. A technique shown to be successful in empowering patients to make relevant lifestyle and behavioural changes is motivational interviewing. In this issue, McKenzie et al12 provide a practical overview of how GPs could use motivational interviewing when caring for patients with multimorbidity.

Multimorbidity poses a great challenge for patients who live with it, and to the healthcare system. Although policymakers in different countries are beginning to consider multimorbidity, there remain gaps in guidelines and policy relevant to healthcare systems in Australia and elsewhere.8 There will be no simple solution to this challenge, but any solution is likely to involve improved integration of the healthcare system11 and patient-centred care delivered by well‑supported GPs.12 


References
  1. Harrison C, Henderson J, Miller G, Britt H. The prevalence of diagnosed chronic conditions and multimorbidity in Australia: A method for estimating population prevalence from general practice patient encounter data. PLoS One 2017;12(3):e0172935. Search PubMed
  2. 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(1):51. Search PubMed
  3. Salisbury C, Johnson L, 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):e12–21. Search PubMed
  4. Lee TA, Shields AE, Vogeli C, et al. Mortality rate in veterans with multiple chronic conditions. J Gen Intern Med 2007;22(Suppl 3):403–07. Search PubMed
  5. Feinstein AR. The pre-therapeutic classification of co-morbidity in chronic disease. J Chronic Dis 1970;23(7):455–68. Search PubMed
  6. Harrison C, Britt H, Miller G, Henderson J. Examining different measures of multimorbidity, using a large prospective cross-sectional study in Australian general practice. BMJ Open 2014;4(7):e004694. Search PubMed
  7. Gordon J, Miller G, Britt H. What are chronic conditions that contribute to multimorbidity? Aust J Gen Pract 47(1–2):21–22. Search PubMed
  8. Chandraratne NK, Pathirathna KGRV, Harrison C, Siriwardena AN. A comparison of policies and guidelines related to multimorbidity in the UK, Australia and Sri Lanka. Aust J Gen Pract 47(1–2):15–19. Search PubMed
  9. Fortin M, Dionne J, Pinho G, Gignac J, Almirall J, Lapointe L. Randomized controlled trials: Do they have external validity for patients with multiple comorbidities? Ann Fam Med 2006;4(2):104–08. Search PubMed
  10. Boyd CM, Darer J, Boult C, Fried LP, Boult L, Wu AW. 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. Search PubMed
  11. Leeder SR, Jowsey T, McNab JW. The experiences of patients and carers living with multimorbid, non-communicable diseases. Aust J Gen Pract 47(1–2):24–27. Search PubMed
  12. McKenzie KJ, Pierce D, Gunn JM. Guiding patients through complexity: Motivational interviewing for patients with multimorbidity. Aust J Gen Pract 47(1–2):8–13. Search PubMed

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