Excerpt

Multimorbidity is usually defined as when an individual has two or more long-term conditions. Measuring the prevalence of multimorbidity is not straightforward since this will vary depending on which conditions are counted, but all recent studies show that multimorbidity is common, becomes more common as people age, and is more common in people from less affluent areas. A recent large UK based study found that 42% of the population had at least one of the 40 conditions counted, and 23% had multimorbidity. Two-thirds of people aged 65 years or over had multimorbidity, and 47% had three or more conditions. People living in the most deprived areas had double the rate of multimorbidity in middle age than those living in the most affluent areas. Put another way, they developed multimorbidity 10-15 years before their more affluent peers. The recognition of multimorbidity associated with socioeconomic depreivation is particularly important as NHS England has a legal duty to have regard to the need to reduce health inequalities. Whereas rates of multimorbidity in older people was largely due to higher rates of physical conditions, in the less affluent multimorbidity was due to combinations of physical and mental health conditions was common.

For many people multimorbidity will present few problems but multimorbidity matters because it is associated with reduced quality of life, higher mortality, polypharmacy and high treatment burden, higher rates of adverse drug events, and much greater health services use including emergency hospital admissions. A particular issue for health services and clinicians is that pharmacological and non-pharmacological treatment regimens can become burdensome in people with complex multimorbidity, and care can become uncoordinated and fragmented. Polypharmacy in people with multimorbidity is often driven by the introduction of multiple drugs intended to prevent future morbidity and mortality, but the case for using such drugs weakens as life expectancy reduces. The absolute difference made by each additional drug may also reduce when people are taking multiple preventative medicines. The implications of multimorbidity for organisation of healthcare are highly variable depending on which conditions an individual has. Groups of conditions which have closely related or concordant treatment, such as diabetes, hypertension and angina pose fewer problems of co-ordination than groups where treatment is discordant, such as people who experience both physical and mental health conditions.

NICE guidelines have been developed for the management of many individual diseases and conditions. The aim of this guideline is to inform patient and clinical decision-making and models of care for people with multimorbidity who would benefit from an individual approach because of high impact on their quality of life or functioning due to their conditions or their treatments. Although this is a particular concern of generalists such as general practitioners or geriatricians, the guideline is also relevant to specialists since many of the patients they care for will have other significant conditions.

Contents

• Guideline Development Group members
• NCGC technical team members
• Acknowledgements
• 1. Guideline summary
  • 1.1. Full list of recommendations
  • 1.2. Key research recommendations
• 2. Introduction
• 3. Development of the guideline
  • 3.1. What is a NICE clinical guideline?
  • 3.2. Remit
  • 3.3. Who developed this guideline?
• 4. Methods
  • 4.1. Developing the review questions and outcomes
  • 4.2. Searching for evidence
  • 4.3. Identifying and analysing evidence of effectiveness
  • 4.4. Identifying and analysing evidence of cost-effectiveness
  • 4.5. Developing recommendations
• 5. People who may benefit from an approach to care that takes account of multimorbidity
  • 5.1. Introduction
  • 5.2. Defining multimorbidity
  • 5.3. Recommendations and link to evidence
• 6. Principles of an approach to care that takes account of multimorbidity
  • 6.1. Introduction
  • 6.2. Principles of care
  • 6.3. Barriers to optimising care
• 7. Identification
  • 7.1. Approach to identification
  • 7.2. Unplanned hospital admissions
  • 7.3. Health-related quality of life
  • 7.4. Admission to a care facility
  • 7.5. Life expectancy risk tools
  • 7.6. Polypharmacy: unplanned hospital admissions, health related quality of life, mortality and admission to care facilities
  • 7.7. Review question: Is polypharmacy associated with a greater risk of unplanned hospital admissions amongst people with multimorbidity?
  • 7.8. Polypharmacy: health-related quality of life
  • 7.9. Polypharmacy: mortality
  • 7.10. Polypharmacy: admission to care facilities
• 8. Frailty
  • 8.1. Introduction
  • 8.2. Review question: What is the most accurate tool for assessing frailty?
  • 8.3. Clinical evidence
  • 8.4. Economic evidence
  • 8.5. Evidence statements
• 9. Delivering an approach to care that takes account of multimorbidity
  • 9.1. Introduction
  • 9.2. Approach to the patient
  • 9.3. Treatment Burden
  • 9.4. Establishing patient preferences, values and priorities
  • 9.5. Effectiveness of interventions from condition-specific guidance
  • 9.6. Stopping drugs: antihypertensive treatment
  • 9.7. Stopping drugs: treatments for osteoporosis
  • 9.8. Stopping drugs: statins
  • 9.9. Developing an individualised management plan
• 10. Interventions to improve care for people with multimorbidity
  • Introduction
  • 10.1. Models of care
  • 10.2. Holistic assessment
• 11. Self-Management
  • 11.1. Introduction
  • 11.2. Review question: What is the clinical- and cost-effectiveness of self-management and expert patient programmes for people with multimorbidity?
  • 11.3. Clinical evidence
  • 11.4. Economic evidence
  • 11.5. Evidence statements
• 12. Format of encounters
  • 12.1. Introduction
  • 12.2. Review question: What format of encounters with healthcare professionals improves outcomes for people with multimorbidity?
  • 12.3. Clinical evidence
  • 12.4. Economic evidence
  • 12.5. Evidence statements
• 13. Reference list
• 14. Acronyms and abbreviations
• 15. Glossary
• Appendices A – Q
  • Appendix A. Scope
  • Appendix B. Declarations of interest
  • Appendix C. Clinical review protocols
  • Appendix D. Health economic review protocol
  • Appendix E. Clinical study selection
  • Appendix F. Health economic study selection
  • Appendix G. Literature search strategies
  • Appendix H. Clinical evidence tables
  • Appendix I. Health economic evidence tables
  • Appendix J. GRADE tables
  • Appendix K. Forest plots
  • Appendix L. Excluded clinical studies
  • Appendix M. Excluded health economic studies
  • Appendix N. Cost-effectiveness analysis: holistic assessment compared to usual care
  • Appendix O. Research recommendations
  • Appendix P. NICE technical team
  • Appendix Q. References

Commissioned by the National Institute for Health and Care Excellence

Funding: National Institute for Health and Care Excellence

Disclaimer: Healthcare professionals are expected to take NICE guidelines fully into account when exercising their clinical judgement. However, the guidance does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of each patient, in consultation with the patient and, where appropriate, their guardian or carer.