The World Health Organization (WHO) surmised that:9
Clinical guidelines review and summarise evidence about the most effective treatments for specific conditions and provide recommendations for their use. However, guidelines are almost always focused on single conditions. For instance, among others, there are individual guidelines for diabetes, asthma and stroke. Guidelines rarely take into account multimorbidity. The randomised trials on which guidelines are based very often exclude people with multiple conditions from taking part. The socioeconomic characteristics of participants in the trials are rarely reported, making it difficult for primary care providers to use the evidence for their diverse patient case mix. The potential for interactions between medications and between conditions makes the application of single disease-based clinical guidelines potentially hazardous for people with multiple conditions.
This raises the need for a set of guiding principles to support practitioners in the identification, assessment and management of patients with multimorbidity.1 The guiding principles need to take into account:
- an awareness of multimorbidity and the broad clustering of conditions, including
- physical health conditions
- mental health conditions
- ongoing conditions
- symptom complexes (eg chronic non-malignant pain, frailty)
- sensory impairment
- alcohol and drug disorders
- the concept that treatment options for the range of conditions a person may have will be based on single disease/condition guidelines, which will most likely be drawn from research on people without multimorbidity. This may also lead to conflicting opinions from different specialists
- that management of additional risk factors for future disease can place unnecessary burden on people with multimorbidity
- that there is a need for a genuine patient-centred approach, including
- a discussion about how the person’s health conditions and their treatments interact and affect quality of life
- a discussion about their goals, preferences and priorities for care
- a discussion about the benefits and risks of treatments (not researched in a group with multimorbidity)
- identifying opportunities for improving coordination and integration of care for the individual
- minimising treatment burden to improve quality and safety.
Identification of multimorbidity
As with a systematic approach to care for any chronic disease, it is helpful to identify the group of patients who will benefit most from a multimorbidity approach. For those living in RACFs, this may include the majority of residents. Nevertheless, explicit identification is an important first principle to delivering systematic care. Given the multiple contributors to multimorbidity, the identification of patients with multimorbidity needs to take a multi-faceted approach. The approach should be based on:10
- a search of the patient’s past records, including electronic medical records
- identifying patients who have hyper-polypharmacy (defined as 15 or more medications). Patients on fewer than 15 medications but at high risk of adverse events may also benefit from management using a multimorbidity approach (refer to Part A. Polypharmacy)
- the use of validated tools – recommendations include
- tools to measure the increase in risk of hospital admission – there are a large number of such tools that have been reviewed by the NSW Agency for Clinical Innovation.11 The lack of integration with electronic medical systems and integrated datasets may limit the ability to use them optimally
- tools to assess frailty (refer to Part A. Frailty )
- opportunistically screening during consultations. Using a tool such as The Instrument for Patient Capacity Assessment (ICAN)12 ‘shifts the focus from the medical condition of the person to their situation in life, identifies what the person values doing and being, explores how healthcare and other resources serve or limit this person, and recognises and cultivates opportunities to advance the person and their situation’.13 For clinicians, this tool recommends asking three questions
- What are you doing when you are not sitting here with me?
- Where do you find the most joy in your life?
- What's on your mind today?
Approaches to multimorbidity
Figure 2 illustrates the approach to managing multimorbidity.
Prevalence of individual conditions in general practice encounters
Purpose of approach to care
Discuss with the patient, their carers and/or alternative decision makers that the purpose of a multimorbidity approach (and the aim of healthcare in general) is to improve the quality of life. Quality of life with multimorbidity may be improved by reducing treatment burden and optimising care by identifying:13
- ways of maximising benefit of existing treatment (eg identifying those at high risk when using osteoporosis medication to manage risks of fracture)
- treatments with limited benefit that may be stopped (eg herbal therapies)
- treatment and follow-up plans with high burden (eg routine follow up with specialists)
- medicines with higher risk of adverse events (eg warfarin and novel oral anticoagulants [NOACs] in a person with a high risk of falls)
- alternative arrangements for follow-up appointments to coordinate care or optimise appointments (eg home visits, community healthcare nursing support, remote pacemaker assessments or telehealth).
Establish burden of illness and treatment
As a minimum, GPs could consider:14
- healthcare tasks being imposed on the patient and/or their carers/family
- factors (eg personal, social, financial) that could exacerbate the burden of treatment in this patient
- consequences of the healthcare tasks imposed on this patient.
Table 1 offers a framework to assist in identifying the burden experienced by the patient15 Given the high prevalence of mental health with increasing physical conditions, patients should also be screened for anxiety and depression, and GPs should also be alert for chronic pain concerns (refer to Part A. Pain and Part A. Mental health
Reproduced with permission from Trevena L. Minimally disruptive medicine for patients with complex multimorbidity. Aust J Gen Pract 2018;47(4):175–79. [Accessed 7 August 2019].
Framework for identifying multimorbidity burden
Establish patient goals, values and priorities
Build on previous conversations, such as those using the ICAN tool, to encourage and explore with patients (or their carers/families and alternative decision makers) the things that are important to them. The aim of managing multimorbidity is to individualise care based on the patient’s personal preferences; therefore, establishing their values, goals and priorities are critical to managing multimorbidity. This should include a discussion about longevity, quality of life, and treatment burden, and an exploration of the person’s attitudes to their treatments and the potential benefits and harms of those treatments.
Reviewing medicines and other treatments
When reviewing medications and treatments, it is important to consider the effectiveness of treatment/s, the duration of treatment trials and the populations in the trial.
The Silver Book Part A chapters on Polypharmacy 12,16 and Deprescribing provide an overview of the approach to managing polypharmacy and identifying opportunities to deprescribe. The chapters highlight tools such as the Screening Tool of Older People’s Prescriptions (STOPP) and Screening Tool to Alert to Right Treatment (START) to not only identify medication-related safety concerns and potential medication to cease, but also medications that the person currently is not taking that may offer benefit. The accredited pharmacist plays a critical role in supporting this component.
Individualised management plan
The outcome of the preceding four steps should be an individualised management plan that:12,16
- documents the patient’s goals, values, preferences and priorities
- includes an action plan of medication and treatments that has details of what is being stopped, what is being changed and what is being started
- details information to support coordination of care and identify who is responsible for coordination of care
- arranges follow-up appointments and review of the care plan, including arrangement for continuity of care, given increasing evidence that shows a positive correlation between quality of care and continuity of care.
This guidance offers a pragmatic approach to managing multimorbidity. The evidence for best practice to manage multimorbidity continues to emerge. What is clear is that ‘one size does not fit all’ and the management of patients with multimorbidity offers a unique opportunity to practice authentic patient-centred care.