Multimorbidity in primary care: developing the research agenda

Multimorbidity - usually defined as the co-existence of two or more long-term conditions in an individual - is the norm rather than the exception in primary care patients 1 , 2 and will become more prevalent as populations age. 3 , 1 Multimorbidity cuts across the vertical paradigms in which most health research and policy is envisaged, supported and carried out, reflecting not only specialist interests in particular problems and diseases, but also the tendency of research to focus on easily defined issues. “Complicated” patients with multimorbidity are usually excluded from such research. Although complexity is under-represented in the research literature, it is common place in general medical practice, where the challenges are “horizontal”, integrating not only at the level of the clinical encounter, but also in the co-ordination of services to support patients with multiple problems. The challenge of carrying out research on multimorbidity is to reflect, investigate, inform and improve these aspects of generalist clinical practice. Given that multimorbidity is a challenge facing practitioners and patients alike it has attracted surprisingly little research interest. 4 The research to date has largely focussed on analysis of the impact of multimorbidity on individuals and healthcare systems, with very few studies examining interventions to improve outcomes. 5 One of ‘multimorbidity's many challenges’ 1 includes setting a research agenda to systematically begin to answer important practical issues in supporting people with multimorbidity. Given the scale and complexity of the task, the first difficulty is simply knowing where to start. In order to gather views from the academic primary care community on the research agenda in multimorbidity we held workshops in Ireland (July 2008) and Scotland (January 2009) under the aegis of the Society for Academic Primary Care and the Scottish School of Primary Care respectively. The workshops were attended by approximately 50 delegates, including patient representatives, primary care professionals, and academics; both explored issues of definition, outcome measures, studies and interventions. The common themes that emerged are outlined below. Defining multimorbidity as the co-existence of two or more chronic diseases is over simplistic, inadequate and often represents the norm in older age groups. A more holistic definition is required that includes not only chronic disease ‘labels’ but also other ‘morbidities’ such as emotional and psychological distress, and even existential or spiritual distress, all of which are socially patterned. There is a need to incorporate levels of severity of problems people face and recognise that many people living with multimorbidity are managing well and do not require additional intervention. There are also challenges relating to what constitutes a chronic condition. For example some conditions may be coded separately but are clinically closely inter-related such as anxiety and depression. Others conditions, such as hyperlipidaemia, are often regarded as risk factors rather than discrete conditions. Decisions regarding whether these conditions should be counted in or out of the multimorbidity tally have an important impact on defining groups for future research. Multimorbidity is not just a condition of old age, and studies must begin to investigate multimorbidity across the life-course. There are particular challenges for primary care practitioners working within healthcare systems where specialist care has become fragmented and the only ‘generalist specialists’ are in Medicine for the Care of the Elderly whose services are age dependent. Particular groups may be especially vulnerable to the effects of multimorbidity, such as certain ethnic groups, those with poor social supports, high levels of socio-economic deprivation, and alcohol or drug addiction problems. Interventions to promote the provision of high quality care that meets the needs of people with multimorbidity is a key area for research, including work on health service utilisation and patients’ views on quality of encounters and services. It will be essential to incorporate the expertise of health economists in this activity, as there are high costs involved and choices to be made in terms of alternative types of interventions. The broad expertise of all disciplines working within the health system needs to be harnessed as some of the therapy professions such as Occupational Therapy have retained a generalist approach with a focus on functioning and quality of life. Medical Sociology and Health Psychology are also important disciplines, both in terms of their strengths in developing and considering theoretical frameworks for interventions and in relation to their familiarity with a range of research methods. Outcome measures will be dependent on the aims of interventions but will need to reflect what matters most to patients, which is the effect of all their conditions on their quality of life and physical functioning. Therefore they should include individualised, patient-centred goals, functional ability, quality of life, and social and existential factors. There may be a need to develop specific assessment and outcome measures for patients with multimorbidity. Methods should include qualitative as well as quantitative approaches, and theoretical and methodological developments should be pursued. For example there are methodological challenges in developing complex interventions for patients with multimorbidity and methodological ‘problems’ that need to be overcome when patients with several different conditions are deliberately included in randomised control trials. Research into multimorbidity has recently been moving up the international agenda, particularly in primary care and Fortin and colleagues in Quebec have called for international collaboration. 1 They have also run workshops on multimorbidity and set up a dedicated website to facilitate communication by way of a virtual research community ( http://www.usherbrooke.ca/medecine_famille/recherche/site_MartinFortin/introduction.htm ). In Scotland, the Scottish School of Primary Care has recently established and funded multiple morbidity as a new research theme, with an agenda set for the next 5 years which aims to build capacity and output in this area. The Scottish Government's Chief Scientist Office has also funded a four year programme of applied NHS research on the development of a complex primary care-based intervention to help patients with multiple morbidity in deprived areas, led by SWM in collaboration with SW, GCMW, and other partners in Glasgow and Dundee. In Ireland there is ongoing research looking at the impact of multimorbidity in younger deprived patients 5 and in patients with chronic respiratory conditions using capture-recapture methodology to identify non-coded patients. There are also two programmes working on developing interventions for individuals with mulrtimorbidity and cardiovascular co-morbidities led by SMS and TOD in Trinity College Dublin and Dr Liam Glynn in NUI Galway. In England, the National Institute for Health Research School for Primary Care has also recently appointed a comorbidity programme lead (Professor Chris Salisbury) and a programme of research is underway (see http://www.nspcr.ac.uk ) and related work on self-care support is also being carried out in Manchester at the National Primary Care Research and Development Centre ( http://www.npcrdc.ac.uk ). With the recent WHO endorsement of primary care 7 and the global move towards primary care-led management of chronic diseases, the stage is set for multiple morbidity management to move to the forefront of what primary care does well. High quality research into the integration of medical care and self-management strategies will hold the key to this success.