How can we treat multiple chronic conditions?

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Two recent events started me thinking. The first involved a patient I heard about from a family medicine resident in clinic. She was an elderly woman with a common complement of problems: diabetes, hypertension, congestive heart failure, depression, and mild renal insufficiency. Balancing her medications was difficult, and she ended up being hospitalised for “tune ups” several times a year. The resident asked me for advice about treating such patients, and we started to look for some evidence based guidelines to help us out.

The second event was the US Institute of Medicine’s publication a few weeks ago of a report on the role of public health in the prevention and treatment of chronic diseases.1 Like all of the institute’s reports, its authors thoughtfully and carefully reviewed the literature on the topic, made recommendations for action, and concluded that more research was needed.

These two events left me very dissatisfied.

We all know that chronic diseases have displaced acute infectious diseases as the leading threats to population health throughout much (but not all) of the world. In the United States, chronic diseases (“slow in progression, long in duration, and devoid of spontaneous resolution”) are responsible for 70% of deaths and cause disability in almost 50 million people.1 This despite the fact that we have lots of effective drugs to treat heart disease, cancer, schizophrenia, and so on and that many patients with chronic illnesses live long, independent lives.

The real problems come when you have a bunch of chronic illnesses. The late, lamented Barbara Starfield (BMJ 2011;343:d4265, doi:10.1136/bmj.d4265) was, characteristically, one of the first to document the difficulties associated with having multiple chronic conditions.2 In 1999 she and others found that 65% of elderly Medicare beneficiaries had multiple chronic conditions. Those with four or more such conditions were 99 times more likely to be admitted to hospital with an “ambulatory care sensitive” diagnosis (one that could have been prevented with appropriate primary care) than patients without a chronic condition. Further, the cost of care rose almost exponentially with the number of diagnoses, with the mean annual Medicare expenditure rising from $211 (£135; €160) for patients with no chronic diseases to $13 973 for those with four.

Similarly, as chronic illness diagnoses go up, health related quality of life goes down.3 This may be because of the diseases themselves or because these patients get less than optimal care, are more likely to have adverse drug reactions, or find it more difficult to participate effectively in their own care.4

Because of the high costs of caring for patients with chronic diseases, a whole industry of disease management programmes has arisen, promising (and often delivering) excellent monitoring and care—and correspondingly decreased costs—for patients with high cost chronic illnesses, but only for individual illnesses. Once enrolled, your patient with heart failure or chronic obstructive pulmonary disease will be subject to well defined disease specific protocols and guidelines that have emerged from evidence based processes and been widely used and tested. Indeed, the clinical practice guideline industry grew in response to the desire and need to find evidence based guidance for important—but individual—conditions. So, when my resident and I went to our usual sources, such as the National Guideline Clearinghouse (www.guideline.gov), we didn’t find anything listed under “multiple chronic conditions.” Guidelines inevitably fail when they are expected to cover all the problems and treatments used in taking care of these complex patients.5

Dealing with all the problems of patients who have multiple chronic conditions is logically a primary care issue, because only the primary care doctor can integrate and coordinate the care needed to treat these patients. A group of family doctors led by a team from the University of Sherbrooke, Quebec, have been at the heart of defining and meeting this challenge, which they outlined very well in the BMJ five years ago.6 They use the shorter term “multimorbidity” for multiple clinical conditions. They pointed out that although we don’t know what the best course of action is for every such patient, “models of collaborative, patient centered, and goal oriented care are more likely to meet the complex needs of patients with multimorbidity.”

In subsequent publications they 7 and others 8 have given examples of the comprehensive, coordinated, community connected care that will be needed to research and deliver optimal care to patients with multimorbidities. Also, the Institute of Medicine’s new report on chronic disease contains a paper in one of its appendices detailing different models of care for patients with chronic conditions.1

The heartening news is that research on how to treat patients with multimorbidities is starting to emerge. The US research journal Annals of Family Medicine has made a home for this work. The current issue has three research studies on multimorbidity, to be followed next month by a group of methods papers.9 A small amount of funding has been provided for this research by the US Agency for Healthcare Research and Quality, but much more is needed, given the enormity and complexity of the task. This seems like a perfect agenda for the brand new (and generously funded) Patient-Centered Outcomes Research Institute created by the US health reform law.10 What could be more patient centred than comparative effectiveness research on multimorbidity?11