Royal College of Surgeons in Ireland Coláiste Ríoga

Royal College of Surgeons in Ireland Coláiste 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 – Di. SC, 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, Mc. Kenzie 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

• Cochrane review • Qualitative study with GPs and pharmacists • Impact of multimorbidity: • Chronic respiratory disease • Diabetes Preclinical phase: Theory Phase I: Modelling • Exploratory trial 1 • Exploratory trial 2 • Proposed cohort study and RCT Phase II: Exploratory trial Phase III: Definitive RCT Continuum of increasing evidence 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

• Cochrane review • Qualitative study with GPs and pharmacists • Impact of multimorbidity: • Chronic respiratory disease • Diabetes Preclinical phase: Theory Phase I: Modelling • Exploratory trial 1 • Exploratory trial 2 • Proposed cohort study and RCT Phase II: Exploratory trial Phase III: Definitive RCT Continuum of increasing evidence 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

• Cochrane review • Qualitative study with GPs and pharmacists • Impact of multimorbidity: • Chronic respiratory disease • Diabetes • Chronic ills of ageing Preclinical phase: Theory Phase I: Modelling • Exploratory trial 1 • Exploratory trial 2 • Proposed cohort study and RCT Phase II: Exploratory trial Phase III: Definitive RCT Continuum of increasing evidence Division of Population Health Sciences

Exploratory trial 1 • 20 patients with Chronic respiratory disease plus 2 other conditions; Age 40 -75 • Intervention: 1. GP reports 2. 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

• Cochrane review • Qualitative exploration of views of GPs and pharmacists • Impact of multimorbidity in diabetes and chronic respiratory disease Preclinical phase: Theory Phase I: Modelling • Exploratory trial 1 • Exploratory trial 2 • Cohort study and proposed RCT Phase II: Exploratory trial Phase III: Definitive RCT Continuum of increasing evidence 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 conditions 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

Division of Population Health Sciences http: //www. bmj. com/highwire/section-pdf/9015/7/1

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

• Cochrane review • Qualitative study with GPs and pharmacists • Impact of multimorbidity: • Chronic respiratory disease • Diabetes Preclinical phase: Theory Phase I: Modelling • Exploratory trial 1 • Exploratory trial 2 • Proposed cohort study and RCT Phase II: Exploratory trial Phase III: Definitive RCT Continuum of increasing evidence 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 comorbid 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 Division of Population Health Sciences