Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn

Division of Population Health Sciences

Royal College of Surgeons in IrelandColáiste Ríoga na Máinleá in Éirinn

Chronic Disease - what happens

when they come in multiples?

Susan Smith


Overview: Multimorbidity

• Background• Why important• Impact

• Research programme

• Policy and healthcare delivery


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


Clinical case

• 59 year old woman• Living alone• IHD; Depression; Neurological condition;

Arthritis• Multiple medications

• Presents with pain in her right shoulder


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


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


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


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 ??


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


Challenges

• Patients– Medications, physical functioning – Concept of treatment burden

• Healthcare providers– Lack of time– Uncertainty and poor evidence base


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



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)?


Research Programme


Phase I: Modelling

Preclinical phase:Theory

• Cochrane review• Qualitative study with GPs

and pharmacists• Impact of multimorbidity:

• Chronic respiratory disease

• Diabetes

Continuum of increasing evidence

• Exploratory trial 1• Exploratory trial 2

• Proposed cohort study and RCT

Phase II: Exploratory trial

Phase III: Definitive RCT


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’


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”



Phase I: Modelling





• Diabetes







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


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


Phase I: Modelling





• Diabetes • Chronic ills of ageing







Exploratory trial 1

• 20 patients with Chronic respiratory disease plus 2 other conditions; Age 40-75

• Intervention:1. GP reports2. Occupational therapy (OT) assessments

and treatment if indicated


Exploratory trial 1

• Results: • 8/20 needed OT• OT group had significant improvements

but intervention intensive+• High levels depression and anxiety• GP reports ineffective


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



Phase I: Modelling


• Cochrane review• Qualitative exploration of

views of GPs and pharmacists

• Impact of multimorbidity in diabetes and chronic respiratory disease



• Cohort study and proposed RCT




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


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


Current HSE policy and multimorbidity?

• Chronic disease management– Integrated care– Multidisciplinary care– Support for self-care

Single condition

s


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


http://www.bmj.com/highwire/section-pdf/9015/7/1


Summary

• 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/


Acknowledgment: All patients and practices who participated in research studies

Questions?


Additional material


Phase I: Modelling





• Diabetes







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 co-morbid conditions

• Comparing outcomes across studies a problem• Identified types of interventions being tested


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


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

Documents

Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn