Challenges of managing people with multimorbidity in today’s healthcare systems

Multimorbidity, commonly defined as the co-existence of two or more chronic conditions
within an individual 1], is now the norm in ageing populations around the world 2]. Furthermore, it is socially patterned, occurring more often and at an earlier age
in patients of lower socioeconomic status (SES) 2], 3]. Thus multimorbidity should not be considered exclusively as an issue of older age,
and affects many people of working age 3], 4]. There are multiple challenges in managing patients with multimorbidity, some of
which are discussed below.

Evidence base and guidelines

Research and guidelines on the management of long term conditions has routinely focused
on single diseases 2], 5]. Patients with multimorbidity are usually excluded from randomised controlled trials
3], 6]. This has led to individual disease management rather than a more holistic approach
5]. A recent systematic review of interventions for patients with multimorbidity found
only ten studies worldwide 7]. There was a particular dearth of studies in high deprivation settings, or that focused
on patients with low SES 7].

There is a thus an urgent need for more interventions to be tested in pragmatic trials
in multimorbid populations, especially in relation to health inequalities, and for
these to inform future guidelines. A NICE guideline on the clinical assessment and
management of multimorbidity is expected to be published next year 8]. Although this will provide welcome guidance to this complex area of practice, the
advice is likely to be generic rather than specific, given the paucity of research
to date.

Polypharmacy

Drug therapy in multimorbidity is a common area of difficulty for both patients and
physicians 5], 9], 10]. Polypharmacy is common in multimorbidity because guidelines are single-disease focused
and advise when to start new drugs but seldom when to stop them. The more LTCs (long
term conditions) a patient has the more medications they are likely to be prescribed
4], 11], 12]. Polypharmacy commonly leads to drug-disease interaction and drug-drug interactions
10], 13].

Specialism

Healthcare systems are largely based around a single-disease paradigm and thus specialist
care of the multimorbid patients is often fragmented and duplicative with an increasing
trend toward super-specialism 1], 3], 14]. This can create multiple problems and barriers to holistic patient centred care.
The pivotal role of generalism in the management of patients with multimorbidity is
becoming increasingly evident. Although in some systems this function can be provided
by a general physician or internist, in countries with a well-developed primary care
system, such as in the UK, much of this role depends on general practitioners (GPs)
15]. Expert generalist care is not just medical care for several conditions, but crucially
combines the biotechnical with the biographical, in what has been termed interpretive
medicine 15] in which a patient-centred approach is tailored to each patients circumstances and
choices.

Treatment burden

Treatment burden describes the demand which patients and their caregivers are placed
under by the healthcare system 16]. This is common in patients with multimorbidity as they manage an increasingly chaotic
medical lifestyle. They must negotiate their way through multiple fragmented appointments,
investigations and medication regimes. As well as being disruptive for the patient
this can also affect adherence 17]. The solution is “minimally disruptive medicine” which aims to reduce the workload
of managing illness by better co-ordinating care and emphasising patient choice 17].

Resources

Managing multimorbidity is hard work for patients 18], 19], and for practitioners 9], 19], especially when compounded with socioeconomic deprivation. Managing patients with
multimorbidity is also financially costly. The more long term conditions a patient
has then the greater their use, and thus cost, of health care. This includes primary
care, secondary care outpatient visits, and hospital admissions 20]. This is also true of potentially avoidable acute admissions, which are increased
by multimorbidity, deprivation and mental health problems 21]. There is a growing recognition that with increasing levels of multimorbidity the
sustainability of current healthcare systems around the world is under threat 22].

Mental-physical multimorbidity

Mental health problems such as depression are known to be common in patients with
multimorbidity and the prevalence of mental health problems increases in a linear
way with increasing numbers of physical conditions within individuals 3], 23]. This has several negative consequences, including the ability of the patient to
manage their conditions. Mental-physical multimorbidity is 2–3 times more common in
patients living in deprived areas compare to those in affluent areas, and thus presents
the GP with increased complexity 1], 24]. Recent work suggests that a collaborative care model may help patients with mental-physical
multimorbidity in primary care 25].

Primary care systems

It is commonplace for general practices in the UK to offer 10 min appointments to
patients regardless of the complexity of their health problem. This is unlikely to
be long enough to comprehensively deal with the complex issues which arise in multimorbidity.
In addition, in areas of high deprivation the inverse care law continues to exist,
leading to shorter consultations, less patient enablement and higher GP stress 26], 27]. Giving longer consultations to patients with complex needs in deprived areas can
increase patient enablement and reduce GP stress 28].

Continuity of care is an important part of the management of patients with complex
health conditions 29]. Patients value seeing the same doctor 30], however this has become more difficult with the primary care reforms in the UK 31].