Multimorbidity's many challenges

Roberto Nardi, MD and Giovanni Scanelli, MD, Internal Medicine Depts,
AUSL of Bologna and Azienda Ospedaliero Universitaria of Ferrara, Italy

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Re: Multimorbidity: a current research priority in the UK

Dear Editor,

We appreciated the editorial by Fortin et al. [1] and related rapid
response by Valderas et al. [2] on the challenges on comorbidity and
multimorbidity in older populations. We would like, firstly, underscore
the differences between the concepts of co-morbidity, multimorbidity and
complexity, as multi-morbidity is not equivalent to co-morbidity and both
do not reflect complexity [3]. Complexity is the property of a “real
world” system that is manifested in the inability of any one schematic
model to adequately capture all of its properties. Complexity science
suggests an alternative model in which illness (and health) result from
complex, dynamic, and unique interactions between different components of
the overall system [4]. Complexity in a patient involves the intricate
entanglement of two or more systems (e.g., body-diseases, family-
socioeconomic status, therapies). As further variables for the “complex
patient” concept, disability (ADL-IADL impairment) and frailty (conceived
as “a physiologic syndrome characterized by decreased reserve and
resistance to stressors, resulting from cumulative decline across multiple
physiologic systems and causing vulnerability to adverse outcomes”) [5]
have to be considered. More and more often, the patients admitted to
internal medicine wards, reflecting primary care clients, are elderly and
have multiple associated morbidities and complex situations [6]. They have
multiple hospital unscheduled re-admissions, up to 45% in one year follow-
up. There is a tendency for them to be “shared” – almost like “frequent
flyers” – by many health care providers. A consistent prevalence of
potential difficult hospital discharges (DHDs) in Internal Medicine has
been described, corresponding to 5-6% in overall discharges from Internal
Medicine wards in Italy. Stroke, chronic cardiovascular diseases,
fractures, chronic pulmonary diseases, cognitive impairment and dementia
are the most frequent causes of hospital DHDs admission. DHDs “flags”
concern very old patients, with a high prevalence of dependency before
acute deterioration and a severe functional dependency on admission,
mostly cognitive impaired, with a high need for nursing care, often
undernourished, with many co-morbidities and a high previous one-year
readmission rate [7].

Multi-morbidity, but, mostly important, complexity, is a current research
priority all over the word, for a shared “real patient”, in every setting
of care of the integrated delivery health-care systems. We believe that
the appropriate discussion about multi-morbidity and complexity has to be
based upon shared comprehensive assessment and communication tools between
primary care and hospitalists. Many models of care may result in the
organization of health services. In a chronic care model it is necessary:
a) to clearly define the profile of patient populations for targeted
disease management programs (DMP) [8], because non specific DMP may be not
effective for all old patients, mainly in those with low-moderate (i.e.
robust, as too simple) or higher (i.e. too complex) levels of frailty; b)
to purpose cost-saving interventions in appropriate cases, with the higher
cost-effectiveness ratio c) to guide people through the system, recurring
to adequate communication and feed-back tools too (the best: one patient-
one record), and to district/family case managers, since a comprehensive
range of services is not enough [9].

According to the emerging national policies of resources shifting out from
hospitals to primary care services, hospitalists, general practitioners
and primary care services organizations have to work together to
facilitate solutions for DHDs and complex patients care, with explicit,
monitored targets to reduce the excessive unscheduled hospital readmission
rate. Further inter-professional research, including consensus pathways
between primary care and hospital areas, are mandatory in the management
of complex older patients.

1. Fortin M, Soubhi H, Hudon C, Bayliss EA, van den Akker M.
Multimorbidity's many challenges. BMJ 2007; 334; 1016-7

2. Valderas JM, Starfield B, Roland M. A research priority in the UK.
BMJ 2007; 334: 1128-9

3. Nardi R, Scanelli G, Corrao S, Iori I, Mathieu G, Cataldi
Amaitrian R. Co-morbidity does not reflect complexity in internal
medicine patients. EJIM 2007 (in press)

4. Wilson T, Holt T, Greenlagh T. Complexity and clinical care. BMJ
2001; 323: 685–8

5. Fried LP, Ferrucci L, Darer J, Williamson JD, Anderson G.
Untangling the concepts of disability, frailty, and comorbidity:
implications for improved targeting and care. J Gerontol A Biol Sci Med
Sci 2004; 59:255–63

6. Nardi R, Scanelli G, Borioni D, Grandi M, Sacchetti C, Parenti M,
Fiorino S, Iori I, Di Donato C, Agostinelli P, Cipollini F, Pelliccia G,
Centurioni R, Pontoriero K. The assessment of complexity in internal
medicine patients. The FADOI Medicomplex Study. EJIM 2007 (in press)

7. Nardi R, Scanelli G, Tragnone A, Lolli A, Kalfus P, Baldini A,
Ghedini T, Bombarda S, Fiadino L, Di Ciommo S. Difficult hospital
discharges in internal medicine wards. Intern Emerg Med 2007 (in press)

8. Krumholz HM, Currie PM, Riegel B, Phillips CO, Peterson ED, Smith
R, Yancy CW, Faxon DP. A Taxonomy for Disease Management Scientific
Statement From the American Heart Association Disease Management Taxonomy
Writing Group. Circulation 2006; 114: 1432-45

9. NHS Care Services Minister Liam Byrne, 2006.
http://www.dh.gov.uk/PublicationsAndStatistics/PressReleases/PressRelase...
(accessed 19 July 2006)

Competing interests:
None declared