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Royal College of Surgeons in Ireland
Coláiste Ríoga na Máinleá in Éirinn
Chronic Disease - what happens
when they come in multiples?
Susan Smith
Division of Population Health Sciences
Overview:
Multimorbidity
• Background
• Why important
• Impact
• Research programme
• Policy and healthcare delivery
Division of Population Health Sciences
Academic general practice grounded
in clinical practice
Chronic disease research: How can we improve
outcomes?
• Organisational approaches
– DiSC, Sphere studies
• Patient oriented interventions
– Family diabetes study, Peer support study
• Multimorbidity
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Clinical case
•
•
•
•
59 year old woman
Living alone
IHD; Depression; Neurological condition; Arthritis
Multiple medications
• Presents with pain in her right shoulder
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Clinical Reality
“Just remember Dr Marshall, my life is like a
swimming pool full of sewage and your job is to
push me up into the shallow end.”
Martin Marshall,
McKenzie Lecture, 2010
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Multimorbidity
• Two or more chronic conditions
• Ireland:
– 66%, aged > 50, in GP setting
– Not just older people
• MM aged 45-64, GMS eligible: 7.5 meds; 11 GP visits
per year
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Impact
• Higher rates mortality, medicines use, health
service use, hospital admissions, psychological
problems such as depression and anxiety
• Poorer quality of life and physical functioning
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Impact: costs
• Costs in Ireland five times higher for patients with four or
more conditions. Have average:
– 11 GP visits per year
– 3 OPD visits
– 3.5 admissions
• Reducing costs:
– ‘Million dollar patients’ Cost savings??
– Reducing avoidable complications for people with
chronic disease by 10% could save ??
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Impact: costs
• ‘Million dollar patients’
– 3,800 (approx) in USA in 2010
– Savings at most $3.8 billion??
vs
• Reducing avoidable complications for people with
chronic disease by 10% could save $40 billion
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Challenges
• Patients
– Medications, physical functioning
– Concept of treatment burden
• Healthcare providers
– Lack of time
– Uncertainty and poor evidence base
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Related issues
• Overlap with frailty in older people
• Link with socioeconomic deprivation
– Men in most deprived group die 18 years earlier
– Develop multimorbidity earlier
– Inverse care law
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Division of Population Health Sciences
Multimorbidity
• Vulnerable patients within this group
– Multiple medicines
– High risk emergency admission
– High service use and costs
– Lack social support
• Need cost effective intervention to improve outcomes
• How to identify those in need of intervention (before it
is too late)?
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Research Programme
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• Cochrane review
• Qualitative study with GPs and
pharmacists
• Impact of multimorbidity:
• Chronic respiratory disease
• Diabetes
Preclinical
phase:
Theory
Phase I:
Modelling
• Exploratory trial 1
• Exploratory trial 2
• Proposed cohort study
and RCT
Phase II:
Exploratory
trial
Phase III:
Definitive RCT
Continuum of increasing evidence
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Qualitative study of experiences’ of GPs and
pharmacists managing multimorbidity
• Focus groups with GPs and pharmacists
• Themes
– Link to multiple medicines and ageing
– Health systems issues relating to lack to time,
interprofessional communication difficulties, and
fragmentation of care
– Individual issues relating to professional roles, clinical
uncertainty, and avoidance
– Patient issues: ‘Not all need intervention’
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Qualitative study of experiences’ of GPs and
pharmacists managing multimorbidity
• Idea of ‘Pandora’s box’
– Limited time
• Coping strategies
“Like eating an elephant, bite off one chunk at a time”
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Division of Population Health Sciences
• Cochrane review
• Qualitative study with GPs and
pharmacists
• Impact of multimorbidity:
• Chronic respiratory disease
• Diabetes
Preclinical
phase:
Theory
Phase I:
Modelling
• Exploratory trial 1
• Exploratory trial 2
• Proposed cohort study
and RCT
Phase II:
Exploratory
trial
Phase III:
Definitive RCT
Continuum of increasing evidence
Division of Population Health Sciences
Impact on chronic disease:
Chronic Respiratory Disease (CRD)
• Cross sectional study in three Dublin general practices
• Results
– 16,946 patients in total and 3.9% CRD
– 60% of these had multimorbidity
– Multimorbidity associated with increasing age and low
socio-economic status
– Increased consultation rates and numbers medicines
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Impact on chronic disease:
Diabetes
• 424 patients with type 2 diabetes
• Results
– 90% two or more conditions
– 25% had five or more chronic conditions
– 189 conditions
• Mismatch between self-report and chart review
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• Cochrane review
• Qualitative study with GPs and
pharmacists
• Impact of multimorbidity:
• Chronic respiratory disease
• Diabetes
• Chronic ills of ageing
Preclinical
phase:
Theory
Phase I:
Modelling
• Exploratory trial 1
• Exploratory trial 2
• Proposed cohort study
and RCT
Phase II:
Exploratory
trial
Phase III:
Definitive RCT
Continuum of increasing evidence
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Exploratory trial 1
• 20 patients with Chronic respiratory disease plus 2
other conditions; Age 40-75
• Intervention:
1. GP reports
2. Occupational therapy (OT) assessments and
treatment if indicated
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Exploratory trial 1
• Results:
• 8/20 needed OT
• OT group had significant improvements but
intervention intensive+
• High levels depression and anxiety
• GP reports ineffective
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Exploratory trial 2
• 30 patients with 2 or more chronic conditions; >40,
recruited prospectively by GP
• Intervention
• Six week, group based, OT-led with some
physiotherapy and medicines management
• Significant improvements in OT and psychosocial
outcomes
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Division of Population Health Sciences
• Cochrane review
• Qualitative exploration of views
of GPs and pharmacists
• Impact of multimorbidity in
diabetes and chronic respiratory
disease
Preclinical
phase:
Theory
Phase I:
Modelling
• Exploratory trial 1
• Exploratory trial 2
• Cohort study and
proposed RCT
Phase II:
Exploratory
trial
Phase III:
Definitive RCT
Continuum of increasing evidence
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Cohort study
• 800 patient over aged 70 with focus on admissions
– Identifying patients with multimorbidity at
increased risk hospital admission
– Risk score
– Interviews with patients and their families who
have experienced recent admission exploring
triggers and potential preventable measures
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Proposed randomised
controlled trial
• Complex intervention to improve outcomes for
vulnerable patients with multimorbidity
– Participants
• MM plus recent admission
– Intervention:
• OT groups, case management and medication review
– Outcomes
• Readmission, self-efficacy, quality of life
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Current HSE policy and
multimorbidity?
• Chronic disease management
– Integrated care
– Multidisciplinary care
– Support for self-care
Single
conditions
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Policy choices
• Support generalist approach
– Medicines management
– Focus on relevant interventions and outcomes
• Target increased risk individuals
– Identification and cost effective intervention
• Reduce burden of care
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http://www.bmj.com/highwire/section-pdf/9015/7/1
Summary
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•
•
•
Multimorbidity important
International relevance
Link to quality of care and cost agenda
Challenges
– Identifying individuals at increased risk
– Delivering cost effective interventions
http://www.healthtalkonline.org/
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Acknowledgment:
All patients and practices who
participated in research studies
Questions?
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Additional material
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• Cochrane review
• Qualitative study with GPs and
pharmacists
• Impact of multimorbidity:
• Chronic respiratory disease
• Diabetes
Preclinical
phase:
Theory
Phase I:
Modelling
• Exploratory trial 1
• Exploratory trial 2
• Proposed cohort study
and RCT
Phase II:
Exploratory
trial
Phase III:
Definitive RCT
Continuum of increasing evidence
Division of Population Health Sciences
Cochrane review of interventions to improve
outcomes for patients with multimorbidity
• Ten studies; all recent randomised controlled trials
• Eight included patients with a broad range of
conditions though elderly; two focused on comorbid conditions
• Comparing outcomes across studies a problem
• Identified types of interventions being tested
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Cochrane review: Interventions
(all had multiple elements)
• Professional
– Education
• Organisational
– Care coordinators; changes to care delivery such
as introduction new team member
• Patient
– Patient education or support groups, individual
care plans
• No financial or regulatory type interventions
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Cochrane review conclusions
• Limited research to date
• Focus on co-morbid conditions or multimorbidity
in older patients
• Results suggest may be more effective to target
interventions towards risk factors or specific
functional difficulties. Organisational models such
as Guided Care disappointing
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