Dickhaus, J

GACD Multi-Morbidity Working Group,

Hurst, JR

Maulik, PK

Miranda, JJ

Pastakia, SD

Siddharthan, T

Soriano, JB

Vedanthan, R

GACD Multi-Morbidity Working Group

UCL Discovery

Commentwww.thelancet.com/lancetgh   Vol 6   December 2018 e1270Global Alliance for Chronic Disease researchers’ statement on multimorbidityThe Global Alliance for Chronic Disease (GACD) is an alliance of health research funders whose research teams form a network of multidisciplinary health-care professionals and researchers. We aim to reduce the impact of non-communicable diseases (NCDs) through a focus on implementation research in low-income and middle-income countries (LMICs) and vulnerable populations in high-income countries (HICs).The GACD has commissioned research on hyper-tension, diabetes, chronic respiratory diseases, mental health, and in 2018, the scale up of hypertension and diabetes interventions. We particularly recognise the importance and challenge of coexisting physical and mental health multimorbidity arising from epidemio-logical transitions (ie, from communicable to non-communicable diseases) and rapid population ageing. Although our initial programmes have not explicitly considered multimorbidity in the context of cancer and chronic infectious diseases such as tuberculosis and HIV, we recognise that multimorbidity in relation to these conditions is also a burgeoning challenge. Notably, very little research has been done to address the coexistence of and potential for reciprocal interactions between the course of NCDs and the natural history of acute or long-term infections.Our collaborative approach resulted in the realisation that multimorbidity was a challenge for all our members. To address this issue, we formed a multidisciplinary multimorbidity working group, listed in the appendix, with the aim of identifying common themes and developing a researchers’ statement on multimorbidity. The full version of the GACD Researchers’ Statement1 highlights the specific data that we considered when collating these themes, and an exemplar case history that illustrates the challenges for those living with multimorbidity in LMICs. The six common themes identified of importance across all our research programmes are: (1) the relevance of multimorbidity to all health-care professionals; (2) the general under-recognition of multimorbidity in health-care provision and research, including research to explore new models of delivery of care; (3) the absence of evidence-based guidelines on approaches to manage patients with multimorbidity leading to undertreatment, mistreatment, and overtreatment (in part driven by the absence of primary evidence due to exclusion of many people with multimorbidity from efficacy trials); (4) the need to provide greater access to expert, proactive holistic primary care that integrates NCDs; (5) the need for improved integration of health-care education, both to health-care providers and to patients and their families, specifically in relation to multimorbidity and including how to best access current models of care; and (6) the need for further research assessing interventions that address the challenge of multimorbidity in LMIC settings (eg, low-cost combination interventions and holistic prevention programmes).The following statement summarised our deliberations: “The GACD research network believes that a greater focus on multimorbidity is overdue and necessary to successfully improve global health outcomes”.1 To achieve the GACD aim of reducing the impact of multimorbidity in LMICs with a switch to healthy active ageing, we identified three strategic objectives.The first objective is greater policy awareness and focus on multimorbidity through integrated proactive chronic care, rather than systems that address single NCDs. Practical examples of how this objective could be achieved include support for education, training, and guideline development that focus on multimorbidity, and policies that make implementation of simple universal interventions—around diet, exercise, reduced exposure to tobacco, indoor and outdoor air pollution, and alcohol—attractive, effective, and practical to implement.The second objective proposes changes in the way that research is commissioned, funded, and delivered when considering NCDs in LMICs, particularly the promotion of working across and between traditional disease, primary care, and specialist boundaries. Pragmatic trial designs are one approach to ensure the effects of interventions are considered holistically, in the situations in which they are developed and treated with shared data dictionaries of disease and broad outcome definitions.Commente1271 www.thelancet.com/lancetgh   Vol 6   December 2018Finally, the third objective aims to have health systems research aligned with universal health coverage. In particular, we aim to improve consideration of the role of proactive primary care and (where appropriate) community health workers in developing knowledge and skills to deliver effective integrated care of multimorbid NCDs. Addressing multimorbidity will help improve health systems and their efficiency, particularly when such systems are weak or fragmented.We present the case for a greater focus on multimorbidity, specifically in relation to non-communicable diseases in LMICs and vulnerable populations in HICs. The current disease-specific approaches hinder research and patient care and the ability to maximise improvements in health outcomes. Only by working collaboratively will we be able to achieve international health targets such as the 2030 Sustainable Development Goals, especially those in relation to NCDs, mental health, and long-term communicable diseases. Success will require working across traditional boundaries and the GACD network provides a practical example of how this can work. With our latest funding call in relation to scale-up of hypertension and diabetes research in partnership with delivery organisations, our shared data dictionaries, and our multidisciplinary working groups, the GACD is leading the development of novel approaches to address multimorbidity in LMICs.*John R Hurst, Julia Dickhaus, Pallab K Maulik, J Jaime Miranda, Sonak D Pastakia, Joan B Soriano, Trishul Siddharthan, Rajesh Vedanthan, on behalf of The GACD Multi-Morbidity Working Group†UCL Respiratory, University College London, London, UK (JRH); Icahn School of Medicine, Mount Sinai Hospital, New York, NY, USA (JD); Research, The George Institute of Global Health, New Delhi, India (PKM); Faculty of Medicine, University of New South Wales, Sydney, New South Wales, NSW, Australia (PKM); Nuffield Department for Women and Reproductive Health, The George Institute of Global Health, University of Oxford, Oxford, UK (PKM); CRONICAS Centre of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru (JJM); Department of Pharmacy Practice, College of Pharmacy, Purdue University, Indianopolis, Indiana, IN, USA (SDP); Department of Pneumology, Instituto de Investigación Hospital Universitario de la Princesa, Universidad Autónoma de Madrid, Madrid, Spain (JBS); Division of Pulmonary and Critical Care, Johns Hopkins University, Baltimore, MD, USA (TS); and Department of Population Health, New York University School of Medicine, New York, NY, USA (RV) j.hurst@ucl.ac.uk†See Appendix for a list of the GACD Multi-Morbidity Working Group members.This statement reflects the perspectives of researchers from the GACD, but it does not necessarily reflect the perspective of the funding agencies. We declare no competing interests. Copyright © 2018 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license.1 Global Alliance for Chronic Diseases. Researchers’ statement on multimorbidity. https://www.gacd.org/perch/resources/global-alliance-for-chronic-diseases-researchers-statement-on-multi-morbidity.pdf (accessed Oct 25, 2018). See Online for appendix

Global Alliance for Chronic Disease researchers' statement on multimorbidity

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Global Alliance for Chronic Disease researchers' statement on multimorbidity

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