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Managing Multimorbidity in Practice

Dr.Kevin Gruffydd-Jones

Box Surgery

Wilts.

Member PCRS(UK)

Respiratory Lead RCGP

Member of NICE COPD

Guidelines Committee and

Asthma/COPD Clinical

Standards Committees.

TAYSIDE CENTRE

BOX

Multimorbidity v co-morbidity

• “Multi Morbidity”

co-existence of 2 or more diseases in one

person (Mercer et al Family Practice

2009.)

• “Co-morbidity”

Presence of other diseases in a person

with a reference disease

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Why bother?

• 15.4 million people in England with at least one long –term condition( DoH 2012)

• Estimated by 2025 increase of 42%

•

• 78% of all GP consultations

• 70% Health and Social Care Budget,

Why bother?

• 60% patients in Scottish Study 2 or more conditions .

More people under 65 than over 65 (Mercer BMJ 2012)

• Canadian Study 69% 18-44, 93% 45-65, 98% >

65(Fortin et al 2007)

• Associated with deprivation. Onset multimorbidity 10-15

years earlier in developing countries(Smith BMJ 2012)

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Why bother?

More Likely to :

Die Early

Be Admitted to Hospital

Poor Quality of Life

Multiple drugs

Poor adherence

Susan Smith BMJ 2012

http://www.pcrs-uk.org/resources/copd_guidelinebooklet_final.pdf

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Patient-Centred Management of Stable COPD in Primary Care

SYMPTOMS?

BREATHLESSNESS

Short acting bronchodilators

(beta agonist/anticholinergic)

for relief of symptoms.

PERSISTENT SYMPTOMS

See pharmacotherapy

Algorithm

PRODUCTIVE COUGH

Consider mucolytics

FUNCTIONAL

LIMITATION ?

MRC score > 3

Optimise pharmacotherapy

(see algorithm)

Offer pulmonary

rehabilitation

Screen for

anxiety/depression

EXACERBATIONS?

(Oral steroids/antibiotics/

Hospital admissions)

Optimise pharmacologic

therapy

Discuss action plans i

including use of standby

oral steroids and antibiotics

HYPOXIA?

Oxygen saturation

< 92% at rest in air)

FEV-1 < 30%

Predicted

Refer for oxygen

assessment

HOLISTIC

CARE

Check social

Support

(e.g. carers and

benefits)

Treat co-morbidities.

Consider Palliative

therapy or secondary

Care referral for

Resistant symptoms

Refer to specialist

Palliative care teams

For end-of-life care.

ALL PATIENTS

Smoking cessation advice

Patient education/self management

Assess co-morbidity,

ASSESS BMI: Dietary Advice >25

Exercise promotion

Pneumococcal vaccination

Annual influenza vaccination

Specialist Dietary Referral if BMI <20

COPD is not just a disease of the lungsCOPD is not just a disease of the lungs

HEART FAILURE

(20%)

Metabolic syndrome

(50% with 1 or more

features)

Depression

(25%patients

FEV-1 <50%)

Osteoporosis

(11%-38%)

40% osteopenic in

“TORCH”

Cachexia/

muscle wasting

Lung function is poorly related to the impact of disease upon the patient(Paul

Jones.PCRJ 2011).

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Co-Morbidities in Practice

Barnett et al Lancet 2012

Co-Morbidities in Practice

Barnett et al Lancet 2012

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Co-Morbidities in Practice

Barnett et al Lancet 2012 COPD 3.5 co-morbidites (v 1.8) Sin et al ERJ 2006

Patient-Centred Management of Stable COPD in Primary Care

HOLISTIC

CARE

Check social

Support

(e.g. carers and

benefits)

Treat co-morbidities.

Consider Palliative

therapy or secondary

Care referral for

Resistant symptoms

Refer to specialist

Palliative care teams

For end-of-life care.

All PATIENTS

Smoking cessation advice

Patient education/self management

Assess co-morbidity

ASSESS BMI: Dietary Advice >25 , Specialist Dietary Referral if BMI <20

Exercise promotion

Pneumococcal vaccination

Annual influenza vaccination

1. FEV-1<30%

2. Recurrent Hospital admissions

3. for acute COPD.

4. Housebound

5. BMI <20

6. On LTOT

Would you be surprised if this patient died within the

next year? (6 months)

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Patient-Centred Management of Stable COPD in Primary Care

HOLISTIC

CARE

Check social

Support

(e.g. carers

benefits)

Treat

co-morbidities.

All PATIENTS

Smoking cessation advice

Patient education/self management

Assess co-morbidity

ASSESS BMI: Dietary Advice >25 , Specialist Dietary Referral if BMI <20

Exercise promotion

Pneumococcal vaccination

Annual influenza vaccination

How does this fit in everyday

management?

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What evidence have we got so

far?

• NOT A LOT!

Managing patients with multimorbidity:

systematic review of interventions in

primary care and community settings

BMJ 2012; 345 doi:

http://dx.doi.org/10.1136/bmj.Susan M Smith,

associate professor of general practice1, Hassan Soubhi, adjunct

professor of family medicine2, Martin Fortin, professor of family

medicine2, Catherine Hudon, associate professor of family

medicine2, Tom O’Dowd, professor of general practice3

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What evidence have we got so

far? • 10 studies looking at interventions in

primary care settings

• 8 out of 10 studies US

• ORGANISATIONAL(Multidisciplinary

team, education , drug review(including

pharmacist)

SELF MANAGEMENT : education ,

structured self-mangement

What evidence have we got so

far?

• Results mixed.

• Some evidence of improvements in

specific areas e.g medicines management

• Results ? Better when specific co-

morbidity looked at and when look at

functional limitation.

• Paucity of economic studies.

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National Survey of Multi-

morbidity in clinical practice

with COPD as an examplar

Dr Shoba Poduval

Clinical Support Fellow and First5 GP

Survey

• 7 point questionnaire uploaded to survey

monkey

– What did you do? How did you do it?

Why? What prompted you?

– Overall impact -how this benefits patients,

staff and the organisation

– Lessons learnt, what went well? What

didn’t work well? Advice for others

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Survey

• Open 29.11.12 - 8.2.13

• Thirty four responses

• Thirteen reviewed- themes

• Five case studies

• Other Practices of note- telehealth

Preliminary Results

Themes

• Motive

• Patient selection &

invitation

• Organisation

• Staff

• Housebound

patients

• Outcomes

• Evaluation

• Challenges

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Motives

• QoF

• PBC/CCG funding

• Improving patient experience

Patient selection & invitation

• Disease registers

• Disease severity stratification

• Specific patient selection criteria

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Staff

• Practice team: GP’s, Nurses, HCA’s,

admin staff

• Community team: District Nurses,

Community Nurses, Social Services,

Pharmacists

• Secondary Care

Housebound

• Visits by GP’s & Community Matrons

• On-going support from Community Matron

& Social Services

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Outcomes

• Patient and staff satisfaction

• More appointment time available

• Medication adherence

• Reduced A&E attendance

• Projected savings

Challenges

• Training

• Organisation- time

• Resources- templates

• Funding

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Discussion

• What is your experience of managing

multimorbidity?

• Challenges?

• Suggestions?

So What do we do in Practice?

Long term

condition Clinics IHD/Diabetes/ Heart

Failure etc.

Chronic Care Model of

Wagner

(Proactive structured

care, supportive self

manage

Care Planning

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CHALLENGES

• Deciding on the co-morbidities

• Content and Integration of Templates

• Management of Housebound

• Medicines Management Review

• Stratifying Risk and use of Community

Teams.