Entete 3

Multimorbidity as a complex systems phenomenon: a series exploring this perspective from the Journal of Evaluation in Clinical Practice

By René Melis
Multimorbidity is one of public health and healthcare’s top priorities. Yet despite this, healthcare continues to struggle to provide solutions to deal with multimorbidity in healthcare that work. It is recognized that our healthcare systems – due to their focus on the acute phase of single diseases – are not well positioned to deal with multimorbidity. Unfortunately, our dealings with changing the system do not easily translate into successes: there are so many stakeholders involved and multimorbidity is interconnected with a huge number of aspects of life and society. Where to begin? Our multimorbidity challenge has all the characteristics of a “wicked problem”: a societal problem that is so complex that is seems difficult or even impossible to solve. In the most recent Complexity Forum of the Journal of Evaluation in Clinical Practice a series of articles explore multimorbidity and how we should shape our healthcare from the perspective of complex systems thinking (http://onlinelibrary.wiley.com/doi/10.1111/jep.12723/full). Rather than a stable, albeit complicated, arrangement of individual elements with predictable results following from inputs in a linear way, a complex system is a dynamic, ecological system in which outcomes seem to emerge quite unpredictably out of the interaction of the starting conditioning. For the reasons mentioned above, this “complexity” approach might fit very well to the multimorbidity challenge.
The series starts with an introductory paper of Dr Joachim Sturmberg and colleagues. Sturmberg, who is a general practitioner as well as a longstanding expert on complexity in health (care systems), together with his colleagues explore how taking multimorbidity as a complexity phenomenon might shape integrated, personalized care differently. Following, this work is commented on by several authors from different perspectives. Being a “wicked problem” neither of these works provide a miracle potion to solve our multimorbidity issue, however, the richness of the perspectives included does shed new light. The famous Cynefin framework (https://hbr.org/2007/11/a-leaders-framework-for-decision-making) for management problems tells us that managing complex problems – and multimorbidity sure is! – has to begin with uncovering the “unknown unknowns” and we need to “probe first, then sense, and then respond”. The latter is what this series hopefully has to offer to the multimorbidity community.

Brazilian Group of Studies about Multimorbidity

By Bruno P Nunes and Sandro R Rodrigues Batista
We are very satisfied to inform the International Research Community on Multimorbidity (an important encouraging community of our work) about the creation of the Brazilian Group of Studies about Multimorbidity (named in Portuguese: Grupo Brasileiro de Estudos sobre Multimorbidade – GBEM). The group is headed by Bruno P Nunes and Sandro R Rodrigues Batista, two researchers from Brazil. The group is already formalized in the Brazilian national research platform of the Brazilian National Council for Scientific and Technological Development
Furthermore, we are described in ResearchGate too
Currently, we have more than 20 Brazilian researchers and some international collaborators, including researchers from Chile, Colombia, EUA, India, Peru, Portugal and Sri Lanka. One of our research goals as a group is to improve epidemiological information about multimorbidity in Low and Middle Income Countries, mainly in Brazil and South America. We are using a platform for planning our work and intend to publish the first scientific results of the partnership by the end of 2017. The articles already published by group members can be viewed in the ResearchGate website. Furthermore, we are looking for researchers interested in cross-country comparisons about a wide range of issues related to multimorbidity (prevalence, patterns, inequalities, use of health services and others) to be included in the GBEM. Contact e-mail for further information: nunesbp@gmail.com/ sandrorbatista@gmail.com/ gbemulti@gmail.com.

Assessing and measuring chronic multimorbidity in the older population

By Amaia Calderón-Larrañaga and Davide L Vetrano
Multimorbidity is one of the main challenges facing health systems worldwide. While its definition as “the simultaneous presence of two or more chronic diseases” is well established, its operationalization is not yet agreed. This study aimed to provide a clinically-driven comprehensive list of chronic conditions to be included when measuring multimorbidity.
Based on a consensus definition of chronic disease, all codes from the International Classification of Diseases 10th revision (ICD-10) were classified as chronic or not by an international team of physicians and epidemiologists specialized in geriatrics and family medicine, and were subsequently grouped into broader categories. Last, we showed proof of concept by applying the classification to older adults from the Swedish National study of Aging and Care in Kungsholmen (SNAC-K).
An initial number of 918 chronic ICD-10 codes were identified and grouped into 60 chronic disease categories. In SNAC-K, 88.6% had ≥2 of these 60 disease categories, 73.2% had ≥3, and 55.8% had ≥4. Once validated, this operational measure of multimorbidity may enable the advancement and evolution of conceptual and theoretical aspects of multimorbidity that will eventually lead to better care.
The publication can be found in the following link:

European guidelines on nutritional support for polymorbid (multimorbid) internal medicine patients

By Filomena Gomes and Philipp Schuetz
The European Society for Clinical Nutrition and Metabolism (ESPEN) holds several guidelines and position papers which guide clinicians in providing nutritional support in particular groups of patients, usually disease or age specific (http://www.espen.org/education/espen-guidelines).
However, many of the patients requiring nutritional support may suffer from multiple diseases. In fact, polymorbidity (multimorbidity) is highly prevalent, affecting more than 70% of the hospitalized adult population, and is associated with higher mortality and costs. In this context, a group of 14 European experts is developing guidelines on nutritional support for polymorbid (multimorbid) internal medicine patients, with the aim to help clinicians who struggle with the uncertainties of applying disease-specific guidelines to their patients who suffer from multiple conditions.
This project, which is endorsed by ESPEN, started with an initial meeting in Zurich, in January 2015, and the methodology used follows the standard operating procedures for ESPEN guidelines (Clinical Nutrition. 2015;34(6):1043-51). The working group has developed 12 important clinical questions, covering different areas of nutritional support: indication, route of feeding, energy, protein, micronutrients, disease-specific nutrients, timing, monitoring and procedure of intervention. Systematic literature searches were conducted in 3 different databases (as well as in secondary sources) resulting in a total of 4532 retrieved abstracts. These abstracts were screened to identify papers which meet the inclusion criteria; the quality of the included papers was evaluated and a level of evidence was assigned, which then resulted in a proposal of 22 recommendations and 4 statements. The first DELPHI online voting for these recommendations and statements is now completed and a final consensus conference will take place in April 2017, which will be followed by the preparation of the manuscript for publication.

Publications on multimorbidity October – December 2016

By Martin Fortin
Our search for papers on multimorbidity that were published during the period October – December 2016 has been completed. As in previous searches, we found many new papers and the list is too long for this venue. Therefore, we have prepared a PDF file that can be accessed following this link.
Probably, there are some publications that were not detected by our search strategy using the terms “multimorbidity”, “multi-morbidity” and the expression “multiple chronic diseases” in PubMed (https://www.ncbi.nlm.nih.gov/pubmed), but we are sure that most publications on the subject are included in the list.
All references are also included in our library. Feel free to share with anyone interested in multimorbidity.

Perceived stress and multimorbidity

By Anders Prior
Multimorbidity and especially mental-physical multimorbidity is an increasing concern worldwide. It is well-known that psychiatric illness impairs the prognosis in persons with chronic physical disease. However, little is known on the impact of non-syndromic mental stress; mental stress is common in the general population, and psychological problems are an increasingly frequent reason for primary care contacts. In two studies, we aimed to determine whether perceived mental stress is associated with potentially preventable hospitalizations and all-cause mortality in persons with various degrees of multimorbidity.
The Danish Civil Registration System allowed us to individually link health survey data with prospectively collected data from Danish health registers creating a unique population-based cohort.  The Danish National Health Survey 2010 provided data on e.g. perceived stress and lifestyle factors on a representative sample of 118,000 Danish citizens aged 25 or older. Danish health registers provided data on hospitalizations, demographic and socioeconomic factors. We developed a new Danish multimorbidity index based on recorded diagnoses and redeemed medicine prescriptions on all Danish citizens identifying 39 mental and physical long-term conditions. We adjusted for and analyzed the modifying effect of multimorbidity on the study outcomes.
In general, we found that high stress perception was associated with multimorbidity, an increased number of potentially preventable hospitalizations and increased all-cause mortality after adjusting for mental-physical multimorbidity, socioeconomic factors and lifestyle where appropriate, and there often seemed to be dose-response relations. In absolute numbers, persons with multimorbidity had a poorer prognosis and psychiatric conditions aggravated this.
This may be the first step to understand the impact of mental stress on physical health, to discuss mental stress in a general practice setting, and to create the foundation for developing potential interventions and practice guidelines for patients with stress in general practice. Hopefully, this may lead to better care and improved life expectancy of people with stress and chronic disease.
Prior A, Fenger-Grøn M, Larsen KK, et al. The association between perceived stress and mortality among people with multimorbidity: A prospective population-based cohort study. Am J Epidemiol. 2016;184(3):199-210.
Prior A, Vestergaard M, Davydow DS, et al. Perceived stress, multimorbidity, and risk for hospitalizations for ambulatory care-sensitive conditions: A population-based cohort study. Med Care. 2017;55(2):131-139.

Different multimorbidity measures affect estimated levels of physical quality of life

By Aline Ramond-Roquin
Health-related quality of life is adversely affected by the presence of multimorbidity in a way that an increasing number of concurrent chronic conditions is associated with lower scores of health-related quality of life. Studies aiming to quantify the impact of multimorbidity on the quality of life show wide heterogeneity in terms of the intensity of this association but these studies also present other important methodological differences such as population studied, measure of quality of life, measure of multimorbidity, etc.
Most operational definitions of multimorbidity have been based on a simple count of conditions which are screened as present or not in a given individual from a predetermined list of conditions. Many different lists of potential conditions have been proposed, with some being as short as six conditions and others as long as 40.
We investigated the influence of the list of conditions on the estimated level of the physical component of health-related quality of life in individuals with multimorbidity and found that the length of the list of candidate conditions considered has a great impact on the estimations of physical health-related quality of life.
This argues for careful methodological consideration when measuring multimorbidity and its association with different outcomes. We conclude that standardization of the measure of multimorbidity is needed to allow the comparison of the results across different studies on multimorbidity.
The article describing this study was published on line (1) and is freely accessible to those interested in this subject.
1) Ramond-Roquin A, Haggerty J, Lambert M, Almirall J, Fortin M: Different Multimorbidity Measures Result in Varying Estimated Levels of Physical Quality of Life in Individuals with Multimorbidity: A Cross-Sectional Study in the General Population. Biomed Res Int. 2016;2016:7845438.

Publications on multimorbidity July – September 2016

By Martin Fortin
Our search for papers on multimorbidity that were published during the period July – September 2016 has been completed. As in previous searches, we found many new papers and the list is too long for this venue. Therefore, we have prepared a PDF file that can be accessed following this link.
Probably, there are some publications that were not detected by our search strategy using the terms “multimorbidity”, “multi-morbidity” and the expression “multiple chronic diseases”, but we are sure that most publications on the subject are included in the list.
All references are also included in our library. Feel free to share with anyone interested in multimorbidity.

Training doctors to manage patients with multimorbidity: a systematic review

By Cliona Lewis and Susan Smith

We have published a systematic review of the literature addressing training of doctors in the management of patients with multimorbidity [1]. Overall, 75,110 citations were screened, of which 68 full-text articles were then assessed for eligibility, and just two studies met the inclusion criteria for the review.
While much has been published about the challenges presented by patients with multimorbidity, the issue of educating doctors to manage these patients has been poorly addressed. The two studies presented in this review implemented and evaluated multimorbidity workshops, and provide a basis for further research. It remains to be determined whether there is a specific need for training of doctors to manage patients with multimorbidity, and if so, how that need can best be met. It also remains to be proven that improving knowledge, skills and confidence of doctors results in improved care of this patient group. We have identified existing literature that provides a platform for management of these patients, and for curriculum development in training doctors in the management of multimorbidity. Incorporation of emerging guidelines and research findings into multimorbidity training curricula for doctors is needed in order to optimise practice and enhance the competence and confidence of doctors in managing this challenging population of patients, with the ultimate aim of improving clinical outcomes.
1) Lewis C, Wallace E, Kyne L, Cullen W, Smith SM. Training doctors to manage patients with multimorbidity: a systematic review. Journal of Comorbidity 2016;6(2):85–94. DOI: 10.15256/joc.2016.6.87

‘Addressing the global challenge of multimorbidity’: Call for written evidence

The Academy of Medical Sciences has recently launched a new working group project on ‘Addressing the global challenge of multimorbidity’ and is seeking your views on multimorbidity as an international health challenge.

Throughout the world, as life expectancy increases, the population incidence of non-communicable diseases is also increasing. Further, communicable diseases, with both their short and long term sequelae, continue to affect millions of people every year. Together, all of these factors mean that multimorbidity has become, and will increasingly be, an international health challenge.

However, currently there is no commonly used framework for defining or more widely understanding multimorbidity. Further, most health related research is currently focused on the prevention and management of disorders in isolation. Consequently, it is difficult to compile a coherent body of research in this area or develop evidence-based strategies for use in healthcare systems. In order to address the challenge of multimorbidity, we must understand the problem better.

The questions outlined in the call for written evidence have therefore been developed to gather information on the definition(s) of multimorbidity, better understand the current knowledge base on multimorbidity as an international health challenge, and to gather opinions about future priorities and opportunities.

This call is part of our process of gathering external input into the project, and we would welcome responses from external stakeholders, including researchers, healthcare professionals, research institutions, funders, industry, patients and members of the public.

The deadline for submission is 30 November 2016.

For more information about the project and to submit a response, please visit the Academy’s website. If you have any questions, please contact Dr Rachel Brown (rachel.brown@acmedsci.ac.uk).