How can we treat multiple chronic conditions?BMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e1487 (Published 29 February 2012) Cite this as: BMJ 2012;344:e1487
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Two thoughts in response to Douglas Kamerow’s article on multimorbidity. Although I agree that primary care physicians, along with the patient themselves, must be at the heart of decision making and coordination of care, do not forget the geriatrician. By training and experience, geriatricians have just this expertise in dealing with multimorbidity, balancing competing guidelines and disease priorities, and helping patients to choose their best path through the disease management maze. It is not the role of the geriatrician to supplant the primary care physician in this process, but when specialist help is needed, comprehensive geriatric assessment and the holistic management approach of geriatricians can be invaluable.
Secondly, the best way to get better information on how to manage multiple problems is to enrol people with multiple problems into trials. Rather than seeking to enrol single diseases and homogenous patient groups with few medications, our trials need to enrol people with six diseases and ten medications, and then use a suitable range of outcome measures that can capture not only the disease-specific benefits, but the comorbidity-related downsides. Then, and only then, will we know if adding the eleventh drug does more harm than good.
Competing interests: MW is a geriatrician who conducts randomised controlled trials on frail older people with multiple comorbid diseases
This article strikes at the heart of a core problem in modern health care. We have recognised that, despite the existence of excellent single pathology guidelines from organisations such as SIGN, QIS (Quality Improvement Scotland) and NICE, we are lacking guidance and advice on how to systematically approach issues around co-morbidity and frailty. In NHS Highland, as an attempt to start tackling this, a group of doctors and pharmacists from primary and secondary care got together to produce a guideline that attempted to give some useful guidance as to how to deal with medication issues raised by frailty and multiple co-morbidity.
The guideline aims to provide some guidance on how to make safe and sensible decisions on prescribing in two often overlapping situations where extra thought and consideration is needed. Firstly, when faced with a patient who is either on or has indications to be on multiple medications; secondly, when a patient is ‘Frail’ in a medical sense. ‘Frailty’ in this guideline is taken to describe a state where a patient has a reduced ability to withstand illness without loss of function.
This is happening right now in the Highlands and we have been heartened by the interest and enthusiasm of GPs locally and colleagues in other parts of Scotland. This is not research but an attempt to implement a policy in response to what research has shown. We see this as an opportunity to improve the quality of care, reduce the burden of iatrogenic disease and redress the balance of care as regards prescribed medicines in patients’ favour. NHS Highland's guideline, Polypharmacy: Guidance for Prescribing In Frail Adults, can be viewed at http://www.nhshighland.scot.nhs.uk/Publications/Documents/Guidelines/id1....
Competing interests: No competing interests
Douglas Kamerow’s article ‘How can we treat multiple conditions’ is timely and should be applauded. Increasingly ageing populations are producing a commensurate increase in multiple chronic conditions, multi-morbidities or co—morbidities, call them what you will, and will continue to do so.
Although space has allowed him to describe it only superficially, the research Douglas describes appears to fall into the commonest of all medical traps – treating diseases rather than people. The key to the successful management of co-morbidities – indeed, to the treatment of all illness – is to ‘see the person in the patient’. That is not easy for doctors who see patients only quite briefly and tend to use that time to focus on their patient’s illnesses. At 68 years of age and with a fine collection of co-morbidities of my own, I speak from experience.
The key to success in treating co-morbidities is to discover what motivates the patient, what his or her ambitions and aspirations are, what he or she would like to be able to do, and then to agree with the patient an individual care plan that accommodates all of his or her conditions, is practicable from the patient’s point of view and which will, as far as may be possible, enable the fulfilment of those aspirations.
Douglas is right to say that dealing with the problems of patients who have multiple chronic conditions is logically a primary care issue but, in the UK at least, that is not as simple as it sounds. In the GP practice I attend, one rarely sees the same GP twice in succession, so ‘continuity of care’ has something of a hollow ring to it. Perhaps there is a case for a GP with a special interest in co-morbidities – or are there so many of us with them that that would leave no GPs to treat acute illnesses?
Competing interests: Peter Lapsley is patient editor of the BMJ