Multimorbidity: The gap between guidelines and the reality in practice

Delivering outcome-focused care to patients with comorbidities is increasingly problematic as in places there is an evidence-based hole in the literature, writes Dr Gerry Morrow.

Dr Gerry Morrow
Dr Gerry Morrow

Multimorbidity is defined as the presence of two or more long-term health conditions. 

Multimorbidity affects almost a quarter of all adults in the UK.1 In older people it is even more common. Younger people with multimorbidity are more likely to have a combination of mental and physical health problems with older people more likely to have multiple physical health problems.

With multimorbidity comes an inevitable litany of problems including, reduced quality of life, burden of disease, burden of treatment, polypharmacy, adverse effects, increased risk of unplanned admission to hospital and premature mortality.2

As a result of financial and demographic pressures and increasing subspecialisation in secondary care GPs have found themselves not so much as ‘ideally placed’ to deal with patients with multimorbidity more ‘placed by default’.

Public health and central bodies exhort clinicians to add ‘years to life’ and ‘life to years’ for a population with increasingly multifaceted mental and physical health problems. Unfortunately, the vehicle of primary care has been increasingly burdened over the past 10 years meaning that the challenge of managing patients with multimorbidity has been squeezed into an ever-busier working week.

Complicated and contradictory advice

Single disease guidelines based on randomised controlled trials (RCTs) with patient exclusions of the precise population of relevance to primary care (over 75 years of age with long term conditions) have led to bewildering complicated and contradictory recommendations and advice.

Delivering outcome-focused care to this population is increasingly problematic as in places there is an evidence-based hole in the literature and we find ourselves relying on clinical acumen, experience and patient preference and disease prioritisation for individuals.

The difficulty with this approach is that disease priorities change over time for patients, vary between doctors (particularly specialists) and may be swayed by internal bias, familiarity with certain medications or illnesses and potentially challenging discussions with relatives or carers.

Attempts have been made to provide doctors with a framework on which to rely for optimal management of these patients. These have included risk stratification,3 disease severity metrics,4 medicines optimisation5 and organisational change methodologies.6

Although some of these exercises may have merit and advance the cause of evidence-based practice in this challenging patient cohort, they can have unintended consequences and founder when they come face-to-face with real-world consultations.

Additionally, problematic messages from the centre have actually militated against preventive primary care service provision. These difficulties include messages encouraging the elderly and ‘at-risk’ groups to attend for a flu jab and finding that primary care has not been afforded sufficient stocks to service demand and a tricky eligibility and exclusion policy for the shingles vaccine determined by narrow and some would say, inconsistent age parameters.

These concerns, in tandem with the difficulty of rationalising appropriate medications can cause problems in a consultation. GPs on the right side of the evidence-base divide find themselves advising stopping medication previously seen as ‘life-saving’ such as statins in the over 75 age group or the cessation of dual antiplatelet therapy one year after the insertion of a stent.

How do we bridge the gap?

So how do we best bridge the gap between published guidelines and the reality of dealing with these patients? Is there an advantage to seeking out recommendations to inform management of this group or do we instead fall trust an ‘eminence-based’ practice attitude?

Are there standards of care which can be delivered in primary care and which are applicable to most of these patients, which will deliver not just improved care but also improved outcomes?

The truthful answer is ‘possibly’. The latest Cochrane review concluded that ‘it is difficult to improve outcomes for people with multiple conditions.’6

The evidence shows that from a health economy perspective, reducing inequality and deprivation is almost certainly more likely to enhance outcomes for people suffering from the problems associated with multimorbidity. This plan of improvement is clearly beyond the reach of primary care. 

In terms of the levers of influence which are accessible to primary care, there is some evidence which points to some targeted interventions providing benefit. In particular, it has been found that when health professionals offer patients, who have identified risk factors for disease, for example coronary artery disease or depression, specific risk factor management and therapy aimed at improving functional capacity, this can have a beneficial impact on reducing premature mortality by up to 7%.7

In this study intensive physiotherapy sessions covered compensatory strategies, home modifications, fall recovery techniques, balance and muscle strength exercises. The mortality reduction persisted for over three years after the sessions. Even this is beyond the capacity of most practices to deliver.

Frustratingly a range of interventions to improve blood pressure, HbA1c, anxiety, health-seeking behaviours, medication adherence and patient-reported health outcomes showed no benefit overall.6

We clearly need improved evidence in order to improve outcomes for patients with multimorbidity.

  • Dr Morrow is medical director of Clarity Informatics and clinical non-executive director of the North East Ambulance Service. He was a GP for 20 years.

References

  1. NICE Clinical Knowledge Summaries. Multimorbidity. Accessed 17.01.2019  
  2. Wallace E, Salisbury C, et al. Managing patients with multimorbidity in primary care. BMJ 2015; 350: h176
  3. Snooks H, Bailey-Jones K, et al. Effects and costs of implementing predictive risk stratification in primary care: a randomised stepped wedge trialBMJ Qual Saf 2018; 0:1–9 doi:10.1136/bmjqs-2018-007976. Accessed 17.01.2019
  4. Boyd CM, Weiss CO, et al. Framework for evaluating disease severity measures in older adults with comorbidityJ Gerontol A Biol Sci Med Sci 2007 62(3): 286-95
  5. O’Mahony D, O’Sullivan D, et al. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing 2015 44(2): 213–8.   
  6. Smith SM, Wallace E, et al. Interventions for improving outcomes in patients with multimorbidity in primary care and community settings. Cochrane Database of Systematic Reviews 2016, Issue 3. Art. N.: CD006560. DOI: 10.1002/14651858.CD006560.pub3.
  7. Gitlin LN, Hauck WW, et al. Long-term effect on mortality of a home intervention that reduced functional difficulties in older adults: results from a randomized trial. J Am Geriatr Soc 2009; 57(3): 476-81. Accessed 17.01.2019

Have you registered with us yet?

Register now to enjoy more articles and free email bulletins

Register

Already registered?

Sign in

Follow Us:

Just published

Oedema - red flag symptoms

Oedema - red flag symptoms

Red flag symptoms to be aware of when a patient presents with pitting or non-pitting...

Nine in 10 doctors fear NHS staff crisis could force them into mistakes

Nine in 10 doctors fear NHS staff crisis could force them into mistakes

Nine in 10 doctors fear a 'toxic combination' of rising workload and understaffing...

Proportion of GP practices with over 20,000 patients triples in five years

Proportion of GP practices with over 20,000 patients triples in five years

The proportion of GP practices in England with over 20,000 patients has more than...

Government's 'Yellowhammer' plan for no-deal Brexit confirms NHS fears

Government's 'Yellowhammer' plan for no-deal Brexit confirms NHS fears

Medicine shortages and an even tougher winter than usual lie ahead for the NHS should...

How GP trainee numbers in England have soared over the past decade

How GP trainee numbers in England have soared over the past decade

With serious concerns over the falling full-time equivalent (FTE) GP workforce in...

DHSC could shelve pension flexibility plans if Treasury overhauls annual allowance

DHSC could shelve pension flexibility plans if Treasury overhauls annual allowance

Plans to create the 'most flexible NHS pensions ever' could be shelved if the Treasury...