Transcript GPST Teaching_Multimorbidity and Complexity_DB

Multimorbidity and complexity in
general practice: from the population to
the individual
Curriculum outcomes
• 3.3.3 Understand and accept the inevitable uncertainty in
primary care problem-solving and the need for development of
strategies that demonstrate this
• 4.1.1 Understand the concept of co-morbidity in a patient
• 4.1.2 Develop your skills to manage the concurrent health
problems experienced by your patient through identification,
exploration, negotiation, acceptance and prioritisation
• 4.2 Promote health and well-being by applying health promotion
and disease prevention strategies appropriately
• 4.3 Manage and co-ordinate health promotion, prevention, cure,
care, rehabilitation and palliation
Overview
• Demographic and Primary care Context
• What do we mean by multimorbidity?
• What do we mean by complexity?
• What challenges does MM present?
• How can we approach these challenges and
complexities?
Demographic and primary care context
• Ageing population
• More chronic disease
• Integration of health and social care
• General practice implementing public health
policies
– Anticipatory care: prevention better than cure
– Shift of resources from secondary to primary care
Population Pyramid, Scotland, by single year of age
1951
100
95
90
85
80
75
70
65
60
Age
55
50
45
40
35
30
25
20
15
10
5
0
60000
40000
20000
0
20000
Population
Males
Female
40000
60000
Population Pyramid, Scotland, by single year of age
1981
100
95
90
85
80
75
70
65
60
Age
55
50
45
40
35
30
25
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15
10
5
0
60000
40000
20000
0
20000
Population
Males
Female
40000
60000
Population Pyramid, Scotland, by single year of age
2001
100
95
90
85
80
75
70
65
60
Age
55
50
45
40
35
30
25
20
15
10
5
0
60000
40000
20000
0
20000
Population
Males
Female
40000
60000
Population Pyramid, Scotland, by single year of age
2011
100
95
90
85
80
75
70
65
60
Age
55
50
45
40
35
30
25
20
15
10
5
0
60000
40000
20000
0
20000
Population
Males
Female
40000
60000
Population Pyramid, Scotland, by single year of age
2021
100
95
90
85
80
75
70
65
60
Age
55
50
45
40
35
30
25
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60000
40000
20000
0
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Population
Males
Female
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60000
Population Pyramid, Scotland, by single year of age
2031
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95
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Age
55
50
45
40
35
30
25
20
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60000
40000
20000
0
20000
Population
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Female
40000
60000
Population Pyramid, Scotland, by single year of age
2041
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95
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70
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60
Age
55
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45
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35
30
25
20
15
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0
60000
40000
20000
0
20000
Population
Males
Female
40000
60000
What do we mean by multimorbidity?
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Co-morbidity?
No. of conditions
Physical vs. Mental
Concordant vs.
Discordant
• Severity?
• Complexity?
• Individuals and
families?
Simple, Complicated, Complex?
Complicated vs. complex?
What do we mean by complexity?
A more manageable approach to complexity?
Also:
• Poor literacy
• Language
barriers
• Transport issues
• Debt problems
• Bad housing
• ….
Multimorbidity in Scotland
The Scottish School of Primary Care’s
Multimorbidity Research Programme.
Multimorbidity is common in Scotland
– The majority of over-65s have 2 or more conditions, and the
majority of over-75s have 3 or more conditions
– More people have 2 or more conditions than only have 1
Most people with any long term condition have
multiple conditions in Scotland
Heart failure
3
9
14
Stroke/TIA
6
14
Atrial fibrillation
7
13
Coronary heart disease
9
Painful condition
18
16
20
21
46
19
47
19
22
Cancer
56
21
18
Hypertension
65
19
14
COPD
62
16
13
Diabetes
74
47
24
23
Epilepsy
17
19
21
17
31
39
23
Asthma
16
48
Dementia
5
Anxiety
13
7
Schizophrenia/bipolar
This condition only
56
21
22
20%
21
64
21
23
0%
12
20
13
29
20
18
17
Depression
35
46
18
40%
36
60%
Percentage of patients with each condition who have other conditions
This condition + 1 other
+ 2 others
80%
+ 3 or more others
100%
Most people with any long term condition have
multiple conditions in Scotland
There are more people in Scotland with
multimorbidity below 65 years than above
Obesity
Why does multimorbidity matter?
• Patients with MM are the main users of health care
• But…
–
–
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Chronic disease management often in disease-specific clinics…
…using checklists based on national guidelines…
…written by committees dominated by specialists…
…based on research in selected patients without co-morbidities
Illness and treatment ‘burden’
Illness burden =
the “work” that
patients and
their families do
to understand
and “live with”
a chronic illness
Treatment burden =
self-care practices that
patients must perform
to manage their
treatments and their
interactions with
healthcare providers*
(*) Gallacher K, May C, Montori VM, Mair FS: Understanding Treatment Burden in Chronic Heart Failure Patients. A Qualitative Study.
Annals of Family Medicine 2011, 9: 235-243
From Ahluwalia et al, Medical
generalism in a modern NHS:
preparing for a turbulent future.
BJGP, 2013; 63: 269-270
Small group exercise
• Mrs A: A 78-year-old woman with
previous MI, type 2 diabetes,
osteoarthritis, COPD and depression.
• Mr B: A 75-year-old man with type 2
diabetes mellitus and COPD
Small group exercise
• 1) medication recommendations
• 2) self-care recommendations
• 3) follow-up recommendations
• What might the patient’s treatment goals
be?
Hughes, McMurdo, Guthrie. Guidelines for people not for diseases: the challenges of applying UK clinical
guidelines to people with multimorbidity. Age and Ageing 2012; 0: 1–8
Recommendations for improving clinical
guidelines
• Summarised and comparable information about the relative benefits
and risks of different recommended treatments would help inform
prioritisation in multimorbid patients
• Existing guidelines should explicitly cross-reference each other when
recommendations are synergistic or contradictory, and identify highrisk interactions between recommended treatments and other
commonly prescribed drugs. (e.g. internet-based format)
• Include a small number of specific patient case examples for common
combinations of comorbidity seen in clinical practice
• Guidelines should note some specific advice for practitioners when
treating older patients (e.g. drug doses or class)
• Concerted action is needed to increase the participation of older
people in clinical trials
Polypharmacy
1.
2.
3.
4.
5.
6.
7.
Identify aims and objectives of
drug therapy
Identify essential drug therapy
Does the patient take unnecessary
drug therapy?
Are therapeutic objectives being
achieved?
Is the patient at risk of ADRs or
suffers actual ADRs?
Is drug therapy cost-effective?
Is the patient willing and able to
take drug therapy as intended?
Potential Responses?
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Patient-centred care
Empathy
Shared decision-making
Enable self-management
“Minimally Disruptive Medicine”
Better coordinated care
Individualised care plans
MORE TIME
in the
consultation?
Improve
CONTINUITY?
– More time in consultations; shorter lists?
• Hospital generalists?
• Trials including patients with co-morbidities
Leadership for complex systems
Evidence-based practice
Professionalism
Uncertainty
• “One may say that the
human ability to understand
may be in a certain sense
unlimited.
Professor Werner Heisenberg
(1901 – 1976)
• But the existing scientific
concepts cover always only
a very limited part of reality,
and the other part that has
not yet been understood is
infinite.”
Vulnerability
Dr Thurstan Brewin
(1921 – 2001)
• “in medicine it is hard to be
sure of anything. We can
only weigh the evidence;
bear in mind individual
lifestyle, hopes, fears, and
wishes; and rely on the
varying proportions of trust
and informed consent that
each patient seems to want
or need.”
Experience and intuition
• “In the varied topography of professional
practice there is a high, hard ground where
practitioners can make effective use of
research-based theory and technique, and
there is a swampy lowland where situations
are confusing ‘messes’ incapable of
technical solution.
Donald Schön
(1930 – 1997)
• The difficulty is that the problems of the high
ground, however great their technical
interest, are often relatively unimportant to
clients or to the larger society, while in the
swamp are the problems of greatest human
concern.”
Responsibility
Aimé Césaire
(1913 – 2008)
• “Beware, my body and my
soul, beware above all of
crossing your arms and
assuming the sterile
attitude of the spectator,
because life is not a
spectacle, because a sea of
sorrows is not a
proscenium, because a man
who cries out is not a
dancing bear.”
Expanding our range of 'literacies'
• Technical literacy is important: knowing the biomedical
science, making the diagnosis etc.
But it must be complemented by:
• physical literacy – subjective and objective understanding of
the body - empathic interpretation;
• emotional literacy - allows the doctor to acknowledge and
witness the patient’s suffering and pain, and to help in the
struggle to find a way forward;
• cultural literacy - enriches the search for meaning with
examples of the way others have made healing sense of the
same sorts of hurt and pain.
• Most important of all is moral literacy - Because making
professional judgements in the face of uncertainty requires
and will always require moral courage.
Summary
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Multimorbidity is the norm
Our patients are complex
Our health system is complex
Existing evidence is inadequate
Think about treatment burden &
polypharmacy
• Engage with patients’ values &
preferences
• We need to expand our range of
‘literacies’ (technical; physical;
emotional; cultural; moral)
Trouble is not my middle name.
It is not what I am.
I was not born for this.
Trouble is not a place
though I am in it deeper than the deepest wood
and I’d get out of it (who wouldn’t?) if I could.
Hope is what I do not have in hell –
not without good help, now. Could you
listen, listen hard and well
to what I cannot say except by what I do?
And when you say I do it for badness
this much is true:
I do it for badness done to me before
any badness that I do to you.
Hard to unfankle this.
But you can help me. Loosen
all these knots and really listen.
I cannot plainly tell you this, but, if you care,
then — beyond all harm and hurt –
real hope is there.
By Liz Lochhead, Scots Makar