Over the past decade the Australian government has initiated a number of health care reforms to address the needs of those with chronic conditions such as diabetes, and heart disease. However, the success of chronic care management models has not been universal. Failure to achieve care goals in some patients might be because many patients have multimorbidity. The recently established Medicare Locals may be well placed to play a central role in providing improved care for those with chronic conditions, and in particular development of management plans that take account of multimorbidity. In this RESEARCH ROUNDup we define some of the key findings central to future discussions of this issue in the Australian setting

Erny-Albrecht, Katrina

McIntyre, Ellen

Flinders Academic Commons

Keep up to date with new Australian primary health care research ISSN 1839-6348 Issue 31 August 2013 K Erny-Albrecht E McIntyre The growing burden of multimorbidity Over the past decade the Australian government has initiated a number of health care reforms to address the needs of those with chronic conditions such as diabetes, and heart disease. However, the success of chronic care management models has not been universal.1,2,3 Failure to achieve care goals in some patients might be because many patients have multimorbidity.2,4 The recently established Medicare Locals may be well placed to play a central role in providing improved care for those with chronic conditions, and in particular development of management plans that take account of multimorbidity.4,5 In this RESEARCH ROUNDup we define some of the key findings central to future discussions of this issue in the Australian setting. Impact on patients and primary health care Compared with single condition patients, those affected by multimorbidities are exposed to greater risk of mortality, hospitalisation, longer hospital stays, and reduced quality of life.2,20 A recent Australian study of multimorbidity found the median monthly time spent on health related activity was 5-16 hours per month, and up to two to three hours per day for those with five or more chronic conditions.21 A report based on 1990s data found that the health care costs for multiple morbidities is greater than the combined cost of the single conditions alone.19 With respect to out-of-pocket expenses, a survey of older Australians found that individuals with five or more chronic conditions spend on average five to six times more than those with no chronic conditions.5 In addition to this, a small study of private health insurance (PHI) among older Australians found that many individuals with multiple chronic conditions struggle financially to maintain PHI at the expense of their quality of life.22 Most models of primary care focus on single chronic conditions or on an index chronic condition, with treatment and care dependent on the central condition and adherence to evidence based medicine (EBM) guidelines. Unfortunately most EBM guidelines do not refer to patients with multimorbidity, and this problem has recently been highlighted in reports demonstrating the impossible care plans resulting from application of current guidelines to representative hypothetical patients.23,24 The challenge in multimorbidity is attempting to respond to each of the conditions that differ with respect to aetiology, care guidelines and prescribed treatments, to improve outcomes whilst supporting patients to self-manage.25 Attempts to identify clusters of chronic conditions in an Australian cohort found no evidence of clustering according to organ or body system, but did observe clinically meaningful clusters of multimorbid conditions.26 Application of this and results from future surveys could provide clinicians with a set of priority multimorbid clusters as a starting point for improved care plans. Moving forward The focus of chronic care management has largely remained on single chronic conditions and according to the Serious and Continuing Illness Policy and Practice Study (SCIPPS) current models are failing to adequately support carers and leave participants with multiple morbidities confused and under financial strain.4,27,28 Current chronic care management What is chronic disease multimorbidity? The World Health Organization (WHO) defines chronic disease as diseases of long duration and generally slow progression.6 In Australia estimates of chronic disease prevalence vary between 50-80% of the adult population.7,8,9 Before embarking on a discussion of chronic disease multimorbidity, it is also useful to clearly define this term since multimorbidity and comorbidity are often used interchangeably yet they represent different health states. Comorbidity is defined as an index (central) disease with one or more comorbid diseases or conditions affecting its course and treatment.10 The most comprehensive attempt to define the term multimorbidity was recently published by the European General Practice Research Network: Any combination of chronic disease with at least one other disease (acute or chronic) or bio-psychosocial factor (associated or not) or somatic risk factor.11 The most commonly used measure of multimorbidity is disease count, specifying whether a person has one or more of a pre-defined list of chronic conditions, but it should be noted that this does not take into account disease severity.12  What is the prevalence of multimorbidity in Australia? The increasing prevalence of multimorbidity has been highlighted in a number of settings, with age and socioeconomic deprivation being identified as significant, contributing factors.8,13-17 The prevalence of multimorbidity within Australia is significant and has been reported in a number of population and clinical studies.5,7,8,17-19 In summarising these studies, the overall prevalence rates for multimorbidity (where eight or more chronic conditions were included) were approximately half of all adults aged between 45 and 65 years, two of every three adults aged 60 years or older, and approaching four of every five adults aged 75 years and older. The number of chronic conditions included is important because studies based on only 4-7 chronic conditions lead to an underestimation of multimorbidity prevalence.15 A consistent finding among the Australian studies, irrespective of design, was that multimorbidity increases with age but is not restricted to the elderly. These findings are in line with studies in other countries, and signal a major disease burden that suggests a need to shift health service away from the current focus on single-diseases.14,15 12 Huntley AL, Johnson R, Purdy S, Valderas JM, Salisbury C. (2012). Measures of multimorbidity and morbidity burden for use in primary care and community settings: a systematic review and guide. Ann Fam Med, 10(2), 134-141. 13 Agborsangaya CB, Lau D, Lahtinen M, Cooke T, Johnson JA. (2012). Multimorbidity prevalence and patterns across socioeconomic determinants: a cross-sectional survey. BMC Public Health, 12, 201. 14 Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B. (2012). Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet, 380(9836), 37-43. 15 Fortin M, Stewart M, Poitras ME, Almirall J, Maddocks H. (2012). A systematic review of prevalence studies on multimorbidity: toward a more uniform methodology. Ann Fam Med, 10(2), 142-151. 16 Marengoni A, Angleman S, Melis R, Mangialasche F, Karp A, Garmen A, et al. (2011). Aging with multimorbidity: a systematic review of the literature. Ageing Res Rev, 10(4), 430-439. 17 Stewart M, Fortin M, Britt HC, Harrison CM, Maddocks HL. (2013). Comparisons of multi-morbidity in family practice--issues and biases. Fam Pract, 30(4), 473-80. 18 Britt HC, Harrison CM, Miller GC, Knox SA. (2008). Prevalence and patterns of multimorbidity in Australia. Med J Aust, 189(2), 72-77. 19 Walker AE. (2007). Multiple chronic diseases and quality of life: patterns emerging from a large national sample, Australia. Chronic Illn, 3(3), 202-218. 20 Boyd C, Fortin M. (2010). Future of Multimorbidity Research: How should understanding of multimorbidity inform health system design? Public Health Reviews, 32(2), 451-474. 21 Jowsey T, McRae IS, Valderas JM, Dugdale P, Phillips R, Bunton R, et al. (2013). Time's up. descriptive epidemiology of multi-morbidity and time spent on health related activity by older Australians: a time use survey. PLoS One, 8(4), e59379. 22 Jeon YH, Black A, Govett J, Yen L, McRae I. (2012). Private health insurance and quality of life: perspectives of older Australians with multiple chronic conditions. Aust J Prim Health, 18(3), 212-219. 23 Guthrie B, Payne K, Alderson P, McMurdo ME, Mercer SW. (2012). Adapting clinical guidelines to take account of multimorbidity. BMJ, 345, e6341. 24 Hughes LD, McMurdo ME, Guthrie B. (2013). Guidelines for people not for diseases: the challenges of applying UK clinical guidelines to people with multimorbidity. Age Ageing, 42(1), 62-69. 25 Roberts RG, Gask L, Arndt B, Bower P, Dunbar J, van der Feltz-Cornelis CM, et al. (2012). Depression and diabetes: the role and impact of models of health care systems. J Affect Disord, 142 Suppl, S80-88. 26 Holden L, Scuffham PA, Hilton MF, Muspratt A, Ng SK, Whiteford HA. (2011). Patterns of multimorbidity in working Australians. Popul Health Metr, 9(1), 15. 27 Aspin C, Jowsey T, Glasgow N, Dugdale P, Nolte E, O'Hallahan J, et al. (2010). Health policy responses to rising rates of multi-morbid chronic illness in Australia and New Zealand. Aust N Z J Public Health, 34(4), 386-393. 28 Essue BM, Jowsey T, Jeon YH, Mirzaei M, Pearce-Brown CL, Aspin C, et al. (2010). Informal care and the self-management partnership: implications for Australian health policy and practice. Aust Health Rev, 34(4), 414-422. 29 Paolucci F, McRae I. (2012). Healthcare delivery for our ageing population: What does Australia need to do? In J.Pincus, G. Hugo (Eds.) A greater Australia: population, policies and governance (pp. 162-174). Australia: Committee for economic development of Australia (CEDA). 30 Ham C. (2010). The ten characteristics of the high-performing chronic care system. Health Econ Policy Law, 5(Pt 1), 71-90. 31 Bird S, Noronha M, Sinnott H. (2010). An integrated care facilitation model improves quality of life and reduces use of hospital resources by patients with chronic obstructive pulmonary disease and chronic heart failure. Aust J Prim Health, 16(4), 326-333. 32 Morgan MA, Coates MJ, Dunbar JA, Reddy P, Schlicht K, Fuller J. (2013). The TrueBlue model of collaborative care using practice nurses as case managers for depression alongside diabetes or heart disease: a randomised trial. BMJ Open, 3(1), pii: e002171. approaches to EBM guidelines and care practices generally do not consider the related consequences for those with multimorbidity such as polypharmacy and care plans that impose considerable burden on an individual in terms of regimen complexity and reduced quality of life20,24. Recent examination of the English health system defined ten characteristics of high-performing chronic care systems, and as noted by Paolucci and McRae, the Australian system is ‘nudging’ in the direction suggested with the establishment of Medicare Locals addressing at least four of the ten criteria.29,30 Boyd and Fortin identified many of the same issues as being necessary in future health system designs to provide appropriate care for those with multimorbidity.20 Guthrie suggested ways in which guidelines could be improved to better address multimorbidity; cross-referencing of guidelines, guidance on treatments most likely to benefit and least likely to harm, and identification of patterns of multimorbidity.23 Perhaps local needs might be best met by a model where Medicare Locals oversee the identification and provision of a range of needed health care services that are coordinated at the patient level by collaborative care partnerships between general practice GPs and their staff, together with specialist consultants to optimise care of patients with multimorbidities whilst ensuring that individual patient needs remain central. Different collaborative care models are being trialled and future approaches could be refined based on outcomes (HARP, TrueBlue, etc.), and whilst Medicare Locals are in their infancy they are moving closer to the goal of coordinating what has been described as a fragmented health system.29,31,32 References 1 Coleman K, Austin BT, Brach C, Wagner EH. (2009). Evidence on the Chronic Care Model in the new millennium. Health Aff (Millwood), 28(1), 75-85. 2 Smith SM, Soubhi H, Fortin M, Hudon C, O'Dowd T. (2012). Managing patients with multimorbidity: systematic review of interventions in primary care and community settings. BMJ, 345, e5205. 3 Zwar N, Harris M, Griffiths R, Roland M, Dennis S, Powell Davies G, et al. (2006). A systematic review of chronic disease managment, Canberra, Australia: Research Centre for Primary Health Care and Equity, School of Public Health and Community Medicine, UNSW. 4 Ceramidas DM, Glasgow NJ. (2013). Multi-morbidity: a system design challenge in delivering patient-centred care. Aust Health Rev, 37(3), 309-311. 5 McRae I, Yen L, Jeon YH, Herath PM, Essue B. (2013). Multimorbidity is associated with higher out-of-pocket spending: a study of older Australians with multiple chronic conditions. Aust J Prim Health, 19, 144-149. 6 World Health Organization. (2013). Health Topics: Chronic diseaes. Retrieved 30 July 2013, from www.who.int/topics/chronic_diseases/en/ 7 Knox SA, Harrison CM, Britt HC, Henderson JV. (2008). Estimating prevalence of common chronic morbidities in Australia. Med J Aust, 189(2), 66-70. 8 Taylor AW, Price K, Gill TK, Adams R, Pilkington R, Carrangis N, et al. (2010). Multimorbidity - not just an older person's issue. Results from an Australian biomedical study. BMC Public Health, 10, 718. 9 Australian Institute of Health and Welfare. (2006). Chronic disease and associated risk factors in Australia 2006. Australia: Australian Institute for Health and Welfare. 10 van den Akker M, Buntinx F, Metsemakers JF, Roos S, Knottnerus JA. (1998). Multimorbidity in general practice: prevalence, incidence, and determinants of co-occurring chronic and recurrent diseases. J Clin Epidemiol, 51(5), 367-375. 11 Le Reste JY, Nabbe P, Manceau B, Lygidakis C, Doerr C, Lingner H, et al. (2013). The European General Practice Research Network presents a comprehensive definition of multimorbidity in family medicine and long term care, following a systematic review of relevant literature. J Am Med Dir Assoc, 14(5), 319-325. The growing burden of multimorbidity Acknowledgements: Thank you to expert reviewer Prof James Dunbar for his comments on a draft of this paper. 

The growing burden of multimorbidity

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