{"id":1006,"date":"2014-12-10T11:01:24","date_gmt":"2014-12-10T16:01:24","guid":{"rendered":"http:\/\/crmcspl-blog.recherche.usherbrooke.ca\/?p=1006"},"modified":"2014-12-10T11:01:24","modified_gmt":"2014-12-10T16:01:24","slug":"multi-morbidity-and-the-emperor%e2%80%99s-new-clothes-a-challenge-for-primary-care-researchers","status":"publish","type":"post","link":"https:\/\/crmcspl-blog.recherche.usherbrooke.ca\/?p=1006","title":{"rendered":"Multi-morbidity and the Emperor\u2019s New Clothes: a challenge for primary care researchers"},"content":{"rendered":"<p><a class=\"twitter-share-button\" href=\"https:\/\/twitter.com\/share\">Tweet<\/a><br \/>\n<script type=\"text\/javascript\">\/\/ <![CDATA[\n!function(d,s,id){var js,fjs=d.getElementsByTagName(s)[0],p=\/^http:\/.test(d.location)?'http':'https';if(!d.getElementById(id)){js=d.createElement(s);js.id=id;js.src=p+':\/\/platform.twitter.com\/widgets.js';fjs.parentNode.insertBefore(js,fjs);}}(document, 'script', 'twitter-wjs');\n\/\/ ]]><\/script><br \/>\nBy Martin Roland<\/p>\n<p><a href=\"https:\/\/crmcspl-blog.recherche.usherbrooke.ca\/wp-content\/uploads\/Martin-Roland-2.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"alignnone size-full wp-image-1008\" title=\"Martin Roland 2\" src=\"https:\/\/crmcspl-blog.recherche.usherbrooke.ca\/wp-content\/uploads\/Martin-Roland-2.jpg\" alt=\"\" width=\"89\" height=\"132\" \/><\/a><br \/>\nAre single disease guidelines and indicators are going out of fashion? Well they are with people interested in multi-morbidity. The argument is straightforward. Single disease guidelines are usually based on trials which exclude people with multiple complex problems. So how does the physician know how a cholesterol guideline developed from trials on 65 year old CHD patients relates to the 85 year old in front of him with seven other comorbid conditions? The risks of polypharmacy are increased as the number of prescribed meds goes up, so what is the physician to do? Does he follow eight disease guidelines for the old lady in front of him? Or is there another way?<br \/>\nWell, <a href=\"http:\/\/cmajblogs.com\/minimally-disruptive-medicine\/\" target=\"_blank\">Victor Montori<\/a> thinks there needs to be. He gave the opening keynote at this year\u2019s <a href=\"http:\/\/www.napcrg.org\/Conferences\/AnnualMeeting\" target=\"_blank\">NAPCRG conference<\/a>. Despite being an endocrinologist, he sees clear problems in attempting to apply multiple single disease guidelines to our increasingly multi-morbid patients. His answers were about meaningful engagement with patients and their priorities, and shared decision making which takes into account a clear explanation of risks, benefits and alternative treatment approaches. That\u2019s good, but it\u2019s not good enough. We\u2019ve opened up an intellectual space by criticising the single disease approach in multi-morbid older populations, but we haven\u2019t yet filled it adequately.<br \/>\nA number of major problems remain. Here are two.<br \/>\nFirst is the assumption that more is worse. This may be true, and certainly polypharmacy is both hazardous and responsible for substantial morbidity. However, although many trials exclude people with multi-morbidity, the absolute risks faced by the very elderly may be greater than for patients included in trials. So the benefits may be greater too. We often just don\u2019t know. But we certainly shouldn\u2019t assume we shouldn\u2019t be treating people just because they\u2019re old and frail. Surprisingly, polypharmacy doesn\u2019t seem to be a risk factor for unscheduled hospital admission in highly multi-morbid patients.<br \/>\nSecond, a primary care physician may be uneasy about the patient in front of him on 15 medications, but it\u2019s hard to know which one to stop. Which diabetic patient doesn\u2019t need tight glucose control? Which stroke patient doesn\u2019t need close blood pressure monitoring? So it\u2019s not only hard for the physician to know if he or she is providing the best care for people, it\u2019s hard for other people to know too. Part of the reason that quality indicators for single diseases have gained such prominence (e.g. in P4P schemes) is that physicians increasingly have to demonstrate that they are providing high quality care. And that won\u2019t go away just because our patients are becoming older and more complex.<br \/>\nSo here\u2019s a real challenge to the academic primary care community. We\u2019ve exposed many of the weaknesses of single disease guidelines and quality indicators. But we haven\u2019t put anything adequate in their place. We\u2019ve opened up an intellectual space, but we haven\u2019t filled it. No-one else is going to lead the way on this. It\u2019s up to us, or the single disease paradigm will continue to dominate.<br \/>\n(This post was originally published in <a href=\"http:\/\/cmajblogs.com\/multimorbidity-a-challenge-for-primary-care-researchers\/\" target=\"_blank\">CMAJBlogs.com<\/a>)<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Tweet By Martin Roland Are single disease guidelines and indicators are going out of fashion? Well they are with people interested in multi-morbidity. The argument is straightforward. Single disease guidelines are usually based on trials which exclude people with multiple complex problems. So how does the physician know how a cholesterol guideline developed from trials <a href=\"https:\/\/crmcspl-blog.recherche.usherbrooke.ca\/?p=1006\"> read more <span class=\"meta-nav\">&raquo;<\/span><\/a><\/p>\n","protected":false},"author":40,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_s2mail":"yes","footnotes":""},"categories":[4],"tags":[],"class_list":["post-1006","post","type-post","status-publish","format-standard","hentry","category-others"],"_links":{"self":[{"href":"https:\/\/crmcspl-blog.recherche.usherbrooke.ca\/index.php?rest_route=\/wp\/v2\/posts\/1006","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/crmcspl-blog.recherche.usherbrooke.ca\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/crmcspl-blog.recherche.usherbrooke.ca\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/crmcspl-blog.recherche.usherbrooke.ca\/index.php?rest_route=\/wp\/v2\/users\/40"}],"replies":[{"embeddable":true,"href":"https:\/\/crmcspl-blog.recherche.usherbrooke.ca\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=1006"}],"version-history":[{"count":4,"href":"https:\/\/crmcspl-blog.recherche.usherbrooke.ca\/index.php?rest_route=\/wp\/v2\/posts\/1006\/revisions"}],"predecessor-version":[{"id":1011,"href":"https:\/\/crmcspl-blog.recherche.usherbrooke.ca\/index.php?rest_route=\/wp\/v2\/posts\/1006\/revisions\/1011"}],"wp:attachment":[{"href":"https:\/\/crmcspl-blog.recherche.usherbrooke.ca\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=1006"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/crmcspl-blog.recherche.usherbrooke.ca\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=1006"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/crmcspl-blog.recherche.usherbrooke.ca\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=1006"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}