Dr David Kernick reviews NICE Guideline 56 on multimorbidity, and identifies the key recommendations for managing people with multiple chronic conditions in primary care

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Read this article to learn more about:

  • identifying problematic multimorbidity in an individual
  • how to tackle treatment burden due to polypharmacy
  • developing an individualised management plan that accounts for multimorbidity.

Key points

GP commissioning messages

 

In 1901 the average life expectancy in the UK was 45 years for men and 49 years for women.1 Since 1901, basic levels of hygiene have dramatically improved and there have been significant advances in healthcare (such as the introduction of antibiotics and vaccinations). This has led to an increase in life expectancy— by 2012 men could expect to live to 79 years of age, and women 83 years, and these figures continue to increase.1

People are living longer with a greater proportion of years of good health, but as a result more people are living longer with multiple medical conditions, creating significant medical, social, and economic challenges.

What is multimorbidity?

Multimorbidity is currently defined as the existence of two or more long-term conditions;2 however, this is not a particularly helpful definition as two-thirds of people aged 65 years and over have multimorbidity, but in the author’s experience, in the majority of cases their multimorbidity has little impact on their function or quality of life.

The prevalence of multimorbidity increases with age (see Figure 1, below).2 In older people, there are not only higher rates of physical health problems but also higher rates of polypharmacy, which give rise to interactions between diseases and the medicines used to treat them; the result of this is more adverse drug events, high treatment burden, and greater use of health and social services. In younger people, multimorbidity is often due to a combination of physical and mental health conditions against a background of poor socioeconomic circumstances.2

Figure 1: Number of disorders as a function of age2

Figure one number of disorders as a function of age 1280x863

Barnett K, Mercer S, Norbury M et al. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet 2012; 380 (9836): 37–43. Reproduced with permission.

It is important for GPs to identify and manage problems arising from multimorbidity where there is potential for care to become burdensome or uncoordinated.

This article discusses the key recommendations in NICE Guideline (NG) 56 on Multimorbidity: clinical assessment and management (published September 2016), which offers pragmatic guidance for the practitioner.3

Identifying when multimorbidity becomes problematic

An important first step is for the GP to be alert to situations where a patient’s multiple conditions, and the medication used to treat these conditions, become problematic to the individual. This can be investigated either opportunistically during routine care or proactively using electronic health records.

Two important markers are unplanned hospital admission and polypharmacy. Other important factors include:3

  • learning disability
  • chronic pain
  • sensory impairment
  • alcohol and substance abuse
  • defined physical and mental conditions such as diabetes or schizophrenia.

Special attention should be paid to individuals who have frailty (reduced resilience or biological/physiological reserve), as this group is particularly at risk of problematic multimorbidity. There are several pragmatic approaches to assessing frailty in primary care, see Box 1, below.

Box 1: Assessing frailty in primary care settings3

When assessing frailty in primary and community care settings, consider using 1 of the following:

  • an informal assessment of gait speed (for example, time taken to answer the door, time taken to walk from the waiting room)
  • self-reported health status (that is, ‘how would you rate your health status on a scale from 0 to 10?’, with scores of 6 or less indicating frailty)
  • a formal assessment of gait speed, with more than 5 seconds to walk 4 metres indicating frailty.

Adapted from National Institute for Health and Care Excellence (2016). Multimorbidity: clinical assessment and management. NICE Guideline 56. Available from: www.nice.org.uk/ng56 NICE has not checked the use of its content in this article to confirm that it accurately reflects the NICE publication from which it is taken.

Taking multimorbidity into account

It is important to create an approach to care that takes account of multimorbidity.

Establish treatment and disease burden

Once multimorbidity has been identified as problematic to the patient, practitioners should establish disease and treatment burden by discussing the following with the patient:3

  • how their health problems interact and how this affects their quality of life
  • the number and type of healthcare appointments they have had and where these take place
  • the number and type of medicines they are taking and problems arising from the medications
  • non-pharmacological treatments such as diets, exercise programmes, and psychological treatments.

Clarify what is important to people with multimorbidity

The next step is to encourage the person to clarify what is important to them. This can include their personal goals, values, and priorities. The practitioner should also ask the person whether they would like their partner, family, and/or carers to be involved in this discussion. Relevant areas for discussion include:3

  • lengthening life
  • maintaining:
    • an active social or family life
    • independence
  • preventing specific adverse outcomes
  • reducing:
    • harms from medicines
    • treatment burden.

Dealing with polypharmacy

Treatment burden caused by polypharmacy is common in people with multimorbidity, especially in those who are frail or have limited life expectancy.

Practitioners should be aware that the evidence behind recommendations in clinical guidance (including NICE guidance) on single health conditions is often based on data from people without multimorbidity and taking fewer prescribed regular medicines. These recommendations may therefore offer limited guidance for patients who have multimorbidity.2,3

To curb treatment burden, practitioners should consider stopping or reducing treatments that offer limited overall benefit to the patient, relative to the burden that they create. It is important to discuss treatment cessation with the patient.3

To help guide decisions on whether a treatment should be reduced or stopped, NG56 includes a database of medicines that enables practitioners to assess the effectiveness of treatments, including information on the duration of treatment trials and the populations studied. The database can be found within the tools and resources section of NICE NG56.3

Following a systematic review of evidence in 2015, NICE made specific recommendations regarding people who have been taking bisphosphonates for osteoporosis for at least 3 years—patients should be advised that there is no further benefit from continuing treatment with bisphosphonates for another 3 years, or any harm from stopping treatment with bisphosphonates after 3 years.3

Unfortunately, due to a lack of available evidence, there are no other specific recommendations on the benefit or harm of stopping any other drug classes, and it is unlikely that this will be forthcoming.3

Agree an individualised management plan with the patient

An individualised management plan should be agreed and recorded for patients with multimorbidity. Elements that should be covered in the management plan are listed in Box 2 (see below).

Box 2: Elements of a management plan for people with multimorbidity3

Agree an individualised management plan with the person, including:

  • goals and plans for future care (including advance care planning)
  • who is responsible for coordination of care
  • how the individualised management plan and the responsibility for coordination of care is communicated to all professionals and services involved
  • timing of follow up and how to access urgent care.

National Institute for Health and Care Excellence (2016). Multimorbidity: clinical assessment and management. NICE Guideline 56. Available from: www.nice.org.uk/ng56 NICE has not checked the use of its content in this article to confirm that it accurately reflects the NICE publication from which it is taken.

Conclusion

An important principle of dealing with multimorbidity is to work closely with other health and social care organisations, ensuring good communication channels, and keeping records of the outcome of discussions with patients and their carers. A multidisciplinary approach that includes management and coordination of care across teams is important, as the majority of cases will be without a rigorous evidence base to underpin treatment. When dealing with multimorbidity there should be a wider acknowledgement of the potential impact of other inputs such as social and economic factors and a more pragmatic approach to therapy and medical intervention.

Current healthcare systems revolve around single-disease approaches, and are becoming increasingly inappropriate as multimorbidity becomes more commonplace in society. Therefore, it is crucial that both primary and secondary care adopt a more holistic model to meet the needs of the ageing population.

Although NICE NG56 could be criticised in offering little other than pragmatic good sense, the guidance is important for several reasons. Firstly, it highlights the increasing relevance of multimorbidity and the range of factors that are involved. Secondly, it highlights the importance of integration of different professional teams and why good communication between them is crucial. Thirdly, despite confirming the absence of evidence in therapeutic management, particularly in the elderly, the guideline should give confidence and support to enable GPs to have difficult discussions about when to withhold treatment, and a degree of medicolegal security if things go wrong.

Only one thing is certain, multimorbidity is not going to go away.

Key points

  • Multimorbidity is:
    • defined as the existence of two or more long-term conditions
    • is not always problematic, but can become so due to age, frailty, polypharmacy, and socioeconomic factors
  • Although polypharmacy is an important element of multimorbidity, there is an absence of evidence on cessation of treatment to guide the practitioner
  • GPs can try to identify adults with problematic multimorbidity either opportunistically during routine check-ups, or using formal search approaches
  • It is important to gain clarification from the patient about what they consider to be important in terms of managing their chronic conditions
  • People with multimorbidity usually have contact with several healthcare and social care teams, so coordination between these teams is important
  • NICE Guideline 56 can help:
    • GPs feel confident about having difficult conversations with patients regarding treatment cessation
    • ease GPs’ concerns about potential medico-legal issues.

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GP commissioning messages

written by Dr David Jenner, GP, Cullompton, Devon

  • NG56 can help clinicians understand the limitations of applying evidence obtained from single-disease clinical trials to people with multimorbidity
  • The recommendations made by NG56 on polypharmacy could be applied by pharmacists during medication reviews and targeted to individuals identified as having multimorbidity
  • Commissioners could seek to facilitate multiprofessional clinical reviews of all people who have an unplanned admission and are identified with multimorbidity at the time of discharge
  • CCGs could:
    • incentivise reviews for all patients taking bisphosphonates for >3 years as part of a prescribing incentive scheme with local practices
    • consider agreeing ethical exception reporting from the QOF where NICE guidance recommends relaxation of certain targets in old and frail patients (e.g. NG28 with diabetes HbA1C targets).

NG=NICE Guideline; QOF=quality and outcomes framework

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Read the Guidelines summary of NG56 on Multimorbidity: clinical assessment and management for more advice on assessing and managing patients who have multiple long-term conditions

References

  1. The King’s Fund. Time to think differently—life expectancywww.kingsfund.org.uk/time-to-think-differently/trends/demography/life-expectancy (accessed 7 February 2017).
  2. Barnett K, Mercer S, Norbury M et al. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet 2012; 380 (9836): 37–43.
  3. NICE. Multimorbidity: clinical assessment and management. NICE Guideline 56. Available at: www.nice.org.uk/guidance/ng56G