royal college of surgeons in ireland coláiste ríoga na máinleá in Éirinn
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Division of Population Health Sciences
Royal College of Surgeons in IrelandColáiste Ríoga na Máinleá in Éirinn
Chronic Disease - what happens
when they come in multiples?
Susan Smith
Division of Population Health Sciences
Overview: Multimorbidity
• Background• Why important• Impact
• Research programme
• Policy and healthcare delivery
Division of Population Health Sciences
Academic general practice grounded in clinical practice
Chronic disease research: How can we improve outcomes?
• Organisational approaches– DiSC, Sphere studies
• Patient oriented interventions– Family diabetes study, Peer support
study• Multimorbidity
Division of Population Health Sciences
Clinical case
• 59 year old woman• Living alone• IHD; Depression; Neurological condition;
Arthritis• Multiple medications
• Presents with pain in her right shoulder
Division of Population Health Sciences
Clinical Reality
“Just remember Dr Marshall, my life is like a swimming pool full of sewage and your job is to push me up into the shallow end.”
Martin Marshall, McKenzie Lecture, 2010
Division of Population Health Sciences
Multimorbidity
• Two or more chronic conditions
• Ireland:– 66%, aged > 50, in GP setting– Not just older people
• MM aged 45-64, GMS eligible: 7.5 meds; 11 GP visits per year
Division of Population Health Sciences
Impact
• Higher rates mortality, medicines use, health service use, hospital admissions, psychological problems such as depression and anxiety
• Poorer quality of life and physical functioning
Division of Population Health Sciences
Impact: costs
• Costs in Ireland five times higher for patients with four or more conditions. Have average:– 11 GP visits per year– 3 OPD visits– 3.5 admissions
• Reducing costs: – ‘Million dollar patients’ Cost savings??– Reducing avoidable complications for people
with chronic disease by 10% could save ??
Division of Population Health Sciences
Impact: costs
• ‘Million dollar patients’ – 3,800 (approx) in USA in 2010– Savings at most $3.8 billion??
vs• Reducing avoidable complications for
people with chronic disease by 10% could save $40 billion
Division of Population Health Sciences
Challenges
• Patients– Medications, physical functioning – Concept of treatment burden
• Healthcare providers– Lack of time– Uncertainty and poor evidence base
Division of Population Health Sciences
Related issues
• Overlap with frailty in older people
• Link with socioeconomic deprivation– Men in most deprived group die 18 years
earlier– Develop multimorbidity earlier– Inverse care law
Division of Population Health Sciences
Division of Population Health Sciences
Multimorbidity
• Vulnerable patients within this group– Multiple medicines– High risk emergency admission– High service use and costs– Lack social support
• Need cost effective intervention to improve outcomes
• How to identify those in need of intervention (before it is too late)?
Division of Population Health Sciences
Research Programme
Division of Population Health Sciences
Phase I: Modelling
Preclinical phase:Theory
• Cochrane review• Qualitative study with GPs
and pharmacists• Impact of multimorbidity:
• Chronic respiratory disease
• Diabetes
Continuum of increasing evidence
• Exploratory trial 1• Exploratory trial 2
• Proposed cohort study and RCT
Phase II: Exploratory trial
Phase III: Definitive RCT
Division of Population Health Sciences
Qualitative study of experiences’ of GPs and pharmacists managing multimorbidity
• Focus groups with GPs and pharmacists• Themes
– Link to multiple medicines and ageing– Health systems issues relating to lack to time,
interprofessional communication difficulties, and fragmentation of care
– Individual issues relating to professional roles, clinical uncertainty, and avoidance
– Patient issues: ‘Not all need intervention’
Division of Population Health Sciences
Qualitative study of experiences’ of GPs and pharmacists managing multimorbidity
• Idea of ‘Pandora’s box’– Limited time
• Coping strategies“Like eating an elephant, bite off one chunk
at a time”
Division of Population Health Sciences
Division of Population Health Sciences
Phase I: Modelling
Preclinical phase:Theory
• Cochrane review• Qualitative study with GPs
and pharmacists• Impact of multimorbidity:
• Chronic respiratory disease
• Diabetes
Continuum of increasing evidence
• Exploratory trial 1• Exploratory trial 2
• Proposed cohort study and RCT
Phase II: Exploratory trial
Phase III: Definitive RCT
Division of Population Health Sciences
Impact on chronic disease: Chronic Respiratory Disease (CRD)
• Cross sectional study in three Dublin general practices
• Results– 16,946 patients in total and 3.9% CRD– 60% of these had multimorbidity– Multimorbidity associated with increasing age
and low socio-economic status – Increased consultation rates and numbers
medicines
Division of Population Health Sciences
Impact on chronic disease: Diabetes
• 424 patients with type 2 diabetes• Results
– 90% two or more conditions – 25% had five or more chronic conditions– 189 conditions
• Mismatch between self-report and chart review
Division of Population Health Sciences
Phase I: Modelling
Preclinical phase:Theory
• Cochrane review• Qualitative study with GPs
and pharmacists• Impact of multimorbidity:
• Chronic respiratory disease
• Diabetes • Chronic ills of ageing
Continuum of increasing evidence
• Exploratory trial 1• Exploratory trial 2
• Proposed cohort study and RCT
Phase II: Exploratory trial
Phase III: Definitive RCT
Division of Population Health Sciences
Exploratory trial 1
• 20 patients with Chronic respiratory disease plus 2 other conditions; Age 40-75
• Intervention:1. GP reports2. Occupational therapy (OT) assessments
and treatment if indicated
Division of Population Health Sciences
Exploratory trial 1
• Results: • 8/20 needed OT• OT group had significant improvements
but intervention intensive+• High levels depression and anxiety• GP reports ineffective
Division of Population Health Sciences
Exploratory trial 2
• 30 patients with 2 or more chronic conditions; >40, recruited prospectively by GP
• Intervention• Six week, group based, OT-led with some
physiotherapy and medicines management
• Significant improvements in OT and psychosocial outcomes
Division of Population Health Sciences
Division of Population Health Sciences
Phase I: Modelling
Preclinical phase:Theory
• Cochrane review• Qualitative exploration of
views of GPs and pharmacists
• Impact of multimorbidity in diabetes and chronic respiratory disease
Continuum of increasing evidence
• Exploratory trial 1• Exploratory trial 2
• Cohort study and proposed RCT
Phase II: Exploratory trial
Phase III: Definitive RCT
Division of Population Health Sciences
Cohort study
• 800 patient over aged 70 with focus on admissions– Identifying patients with multimorbidity
at increased risk hospital admission– Risk score– Interviews with patients and their
families who have experienced recent admission exploring triggers and potential preventable measures
Division of Population Health Sciences
Proposed randomised controlled trial
• Complex intervention to improve outcomes for vulnerable patients with multimorbidity– Participants
• MM plus recent admission
– Intervention:• OT groups, case management and medication
review
– Outcomes• Readmission, self-efficacy, quality of life
Division of Population Health Sciences
Current HSE policy and multimorbidity?
• Chronic disease management– Integrated care– Multidisciplinary care– Support for self-care
Single condition
s
Division of Population Health Sciences
Policy choices
• Support generalist approach– Medicines management– Focus on relevant interventions and
outcomes
• Target increased risk individuals– Identification and cost effective
intervention• Reduce burden of care
Division of Population Health Sciences
http://www.bmj.com/highwire/section-pdf/9015/7/1
Division of Population Health Sciences
Summary
• Multimorbidity important• International relevance• Link to quality of care and cost agenda• Challenges
– Identifying individuals at increased risk– Delivering cost effective interventions
http://www.healthtalkonline.org/
Division of Population Health Sciences
Acknowledgment: All patients and practices who participated in research studies
Questions?
Division of Population Health Sciences
Additional material
Division of Population Health Sciences
Phase I: Modelling
Preclinical phase:Theory
• Cochrane review• Qualitative study with GPs
and pharmacists• Impact of multimorbidity:
• Chronic respiratory disease
• Diabetes
Continuum of increasing evidence
• Exploratory trial 1• Exploratory trial 2
• Proposed cohort study and RCT
Phase II: Exploratory trial
Phase III: Definitive RCT
Division of Population Health Sciences
Cochrane review of interventions to improve outcomes for patients with multimorbidity
• Ten studies; all recent randomised controlled trials• Eight included patients with a broad range of
conditions though elderly; two focused on co-morbid conditions
• Comparing outcomes across studies a problem• Identified types of interventions being tested
Division of Population Health Sciences
Cochrane review: Interventions (all had multiple elements)
• Professional– Education
• Organisational– Care coordinators; changes to care delivery
such as introduction new team member• Patient
– Patient education or support groups, individual care plans
• No financial or regulatory type interventions
Division of Population Health Sciences
Cochrane review conclusions
• Limited research to date • Focus on co-morbid conditions or
multimorbidity in older patients• Results suggest may be more effective to
target interventions towards risk factors or specific functional difficulties. Organisational models such as Guided Care disappointing
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