Managing patients with multimorbidity in primary careBMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h176 (Published 20 January 2015) Cite this as: BMJ 2015;350:h176
All rapid responses
We agree with the authors of “Managing patients with multimorbidity in primary care” on the significance of multimorbidity in the ageing of patients and on its impact on their quality of life, the increase in treatment burden they experience and the likelihood of additional health service utilization. Multimorbidity represents chronicity that is difficult to manage disease by disease or through the use of pharmaceutical agents and a more holistic approach is called for. The encouragement of primary care to assume the responsibility of complex care management is commendable and the appraisal of the challenges for primary care realistic. Our concern is that the challenges described are both increased and somewhat different if the person also has an intellectual disability. As deinstitutionalization efforts and associated encouragement of accessing of community based health services increase, people with intellectual disabilities are ageing in the community, are experiencing increased multimorbidity and are increasingly present in primary care caseloads. Their multimorbidity experiences are also different.
Recent data from the nationally representative sample utilized in the Intellectual Disability Supplement to the Irish Longitudinal Study on Ageing (IDS-TILDA) has highlighted:
- There was a 71.2% rate of multimorbidity (2 chronic conditions or more) among the participants who were aged 40 years and old
- Although rates of multimorbidity did increase with age, the rate was 63% for those aged 40-49 years
- Women were twice as likely to be multimorbid as men.
- The emphasis on cardiovascular/metabolic conditions noted by the authors here were not replicated in IDS-TILDA; instead neurological, mental health, gastrointestinal and eye disease were most likely to be co-morbid conditions
(McCarron et al., 2013)
For these reasons, in the preparation of primary care practitioners to assume care of anyone with multimorbidity, there must also be education on the higher rates of comorbidity at earlier ages and for women and the different patterns of multimorbidity among people with intellectual disability. The authors highlighting of a “painful condition factor” in reported multimorbidity factor analyses is also of note; people with an intellectual disability are even more likely to under-report associated pain, particularly given that a number will lack the language skills to self-report. An additional concern is that people with an intellectual disability are less likely to participate in preventive interventions, health promotion and self-management training (McCallion et al., 2013). A critical challenge is both the levels of health literacy among people with intellectual disability and the lack of “easy read” materials targeting their education about the types of chronic conditions they will face. There is a critical need for the development and distribution of such materials.
Primary care physicians themselves should seek additional preparation to understand health issues which are different as well as effective communication approaches for people with intellectual disability. This is an area where collaboration with intellectual disability services agencies will help with the needed supports. The regular planned reviews and attention to continuity of care proposed by the authors we also support but we wish to point out that there is evidence of many people with intellectual disability being afraid of attending health clinics and sometimes being uncooperative in health reviews; suitable responses will require innovative approaches, time and planning for success. The authors’ acknowledgement of the challenge posed by 10 minute health screen approaches for all is of even more concern for care of people with intellectual disability who are multimorbid; the building of trust and complexity in examination will simply require additional time. Devoting such time is important!
As was recently noted in a review of deaths of people with intellectual disability in the UK, there is a higher rate of avoidable deaths in people with intellectual disability (as compared to the general population) from causes where better health care would have made a difference and inattention to needed changes in care as chronic conditions progress was a highlighted contributor (Heslop et al., 2014)
We agree with the authors’ recommendations to take a more interdisciplinary approach to care, and to undertake targeted assessments of chronic diseases, as well as psychological and functional assessment but we recommend that these interventions be expanded to include intellectual disability specific tools and again, collaboration with staff in intellectual disability services who may assist not only with assessment but also with subsequent care plan implementation.
In the recent past improved responses to health concerns such as upper respiratory disease among people with intellectual disabilities contributed to their increased longevity. However, increased longevity has also been associated with increased multimorbidity. Primary care playing its role in the management of multimorbidity will be important to assuring that there is quality of life during that increased longevity. Ageing in poor health is an empty prize!
Heslop, P., Blair, P.S., Fleming, P.J., Hoghton, M.A., Marriott, A.M., & Russ, L.S. (2014). The Confidential Inquiry into premature deaths of people with intellectual disabilities in the UK: a population-based study. Lancet, 383(9920), 889–895.
McCallion, P. Burke, E., Swinburne, J., McGlinchey, E., Carrol, R., & McCarron, M. (2013). Influence of environment, predisposing, enabling and need variables on personal health choices of adults with intellectual disability. Health, 5(4), 749-756.
McCarron, M., Swinburne, J., Burke, E., McGlinchey, E., Carroll, R., & McCallion P. (2013). Patterns of Multimorbidity in an Older Population of Persons with an Intellectual Disability: Results from the Intellectual Disability Supplement to the Irish Longitudinal Study on Ageing (IDS-TILDA). Research in Developmental Disabilities. 34, 521–527.
Competing interests: No competing interests
The concept of multimorbidity management in primary health care settings is innovative. Can such an approach be initiated in the Indian health care system ? If the current status of organizing health care delivery in India is analyzed, one can say that there are numerous problems that plague the system. There is a problem of inequitable distribution of health centres, though the government aims to provide equitable health care to the people. Another problem is that of lack of manpower, which is again distributed in a skewed manner. In some states in the north-eastern India, it has been reported that there is an excess of doctors viz. in Assam, Manipur, Sikkim and Tripura, whereas other states require more doctors such as Arunachal Pradesh (5.15%), Meghalaya (4.59%), Mizoram (35.09%), Nagaland (19.84%), while all India figures shows a deficiency of 12% doctors (1). In such a condition, there could be wide variations in the provision of primary health care in various states of India.
Under normal circumstances, primary health care in India attends to minor ailments, and those that can be tackled at the primary care level without supportive advanced laboratory facilities. This situation cannot deal with multiple problems of the older age or with patients having multiple problems. At best, we cannot expect a patient to be hospitalized at the primary health centre (PHC) in absence of adequate manpower, supportive nursing staff, equipments, and medications. A person coming with myocardial infarction at the PHC may not get appropriate primary management and it needs only referral to a district hospital having cardiac care unit (which in many hospitals is still lacking). Considering the above facts, India still needs to focus on the basic primary care approach of dealing with minor ailments at the PHC level, and treating multiple morbid conditions remains a distant goal to achieve.
1. Saikia D, Das KK. Status of rural health infrastructure status of rural health infrastructure status of rural health infrastructure in the north-east india. Available at: http://journal.managementinhealth.com/index.php/rms/article/viewFile/318... (accessed 27th January 2015)
Competing interests: No competing interests
Multimorbidity poses a number of complex challenges for the NHS health systems, patients and clinicians. In November 2014, the National Institute for Health Research (NIHR) and the Royal College of General Practitioners jointly hosted a Multimorbidity Research Workshop, attended by more than fifty leading experts in managing long-term conditions (Hobbs, Baker & Davies BJGP in press). Part of the aims of the workshop was to identify and to prioritise questions for research which might improve patient experience and management, both in primary and hospital care. This highlighted the comparative lack of evidence, other than descriptive surveys, to guide clinical practice.
This has led to a NIHR themed research call on multimorbidity in older people, launched on 27 January 2015 (http://www.themedcalls.nihr.ac.uk/multimorbidities/home). This call will support research which aims to enable patients with more than one long-term condition to maintain their capabilities and quality of life, and support the NHS to achieve this. Examples of suitable research might include management of multimorbidity, interventions that prevent acute admission to hospital, new approaches to the delivery of services to support a patient centred approach to care, or promotion of health and active life in older age. Further details of closing dates and how to apply are available on the website.
Competing interests: My position is funded by NIHR