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Managing Multimorbidity in Practice
Dr.Kevin Gruffydd-Jones
Box Surgery
Wilts.
Member PCRS(UK)
Respiratory Lead RCGP
Member of NICE COPD
Guidelines Committee and
Asthma/COPD Clinical
Standards Committees.
TAYSIDE CENTRE
BOX
Multimorbidity v co-morbidity
• “Multi Morbidity”
co-existence of 2 or more diseases in one
person (Mercer et al Family Practice
2009.)
• “Co-morbidity”
Presence of other diseases in a person
with a reference disease
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Why bother?
• 15.4 million people in England with at least one long –term condition( DoH 2012)
• Estimated by 2025 increase of 42%
•
• 78% of all GP consultations
• 70% Health and Social Care Budget,
Why bother?
• 60% patients in Scottish Study 2 or more conditions .
More people under 65 than over 65 (Mercer BMJ 2012)
• Canadian Study 69% 18-44, 93% 45-65, 98% >
65(Fortin et al 2007)
• Associated with deprivation. Onset multimorbidity 10-15
years earlier in developing countries(Smith BMJ 2012)
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Why bother?
More Likely to :
Die Early
Be Admitted to Hospital
Poor Quality of Life
Multiple drugs
Poor adherence
Susan Smith BMJ 2012
http://www.pcrs-uk.org/resources/copd_guidelinebooklet_final.pdf
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Patient-Centred Management of Stable COPD in Primary Care
SYMPTOMS?
BREATHLESSNESS
Short acting bronchodilators
(beta agonist/anticholinergic)
for relief of symptoms.
PERSISTENT SYMPTOMS
See pharmacotherapy
Algorithm
PRODUCTIVE COUGH
Consider mucolytics
FUNCTIONAL
LIMITATION ?
MRC score > 3
Optimise pharmacotherapy
(see algorithm)
Offer pulmonary
rehabilitation
Screen for
anxiety/depression
EXACERBATIONS?
(Oral steroids/antibiotics/
Hospital admissions)
Optimise pharmacologic
therapy
Discuss action plans i
including use of standby
oral steroids and antibiotics
HYPOXIA?
Oxygen saturation
< 92% at rest in air)
FEV-1 < 30%
Predicted
Refer for oxygen
assessment
HOLISTIC
CARE
Check social
Support
(e.g. carers and
benefits)
Treat co-morbidities.
Consider Palliative
therapy or secondary
Care referral for
Resistant symptoms
Refer to specialist
Palliative care teams
For end-of-life care.
ALL PATIENTS
Smoking cessation advice
Patient education/self management
Assess co-morbidity,
ASSESS BMI: Dietary Advice >25
Exercise promotion
Pneumococcal vaccination
Annual influenza vaccination
Specialist Dietary Referral if BMI <20
COPD is not just a disease of the lungsCOPD is not just a disease of the lungs
HEART FAILURE
(20%)
Metabolic syndrome
(50% with 1 or more
features)
Depression
(25%patients
FEV-1 <50%)
Osteoporosis
(11%-38%)
40% osteopenic in
“TORCH”
Cachexia/
muscle wasting
Lung function is poorly related to the impact of disease upon the patient(Paul
Jones.PCRJ 2011).
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Co-Morbidities in Practice
Barnett et al Lancet 2012
Co-Morbidities in Practice
Barnett et al Lancet 2012
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Co-Morbidities in Practice
Barnett et al Lancet 2012 COPD 3.5 co-morbidites (v 1.8) Sin et al ERJ 2006
Patient-Centred Management of Stable COPD in Primary Care
HOLISTIC
CARE
Check social
Support
(e.g. carers and
benefits)
Treat co-morbidities.
Consider Palliative
therapy or secondary
Care referral for
Resistant symptoms
Refer to specialist
Palliative care teams
For end-of-life care.
All PATIENTS
Smoking cessation advice
Patient education/self management
Assess co-morbidity
ASSESS BMI: Dietary Advice >25 , Specialist Dietary Referral if BMI <20
Exercise promotion
Pneumococcal vaccination
Annual influenza vaccination
1. FEV-1<30%
2. Recurrent Hospital admissions
3. for acute COPD.
4. Housebound
5. BMI <20
6. On LTOT
Would you be surprised if this patient died within the
next year? (6 months)
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Patient-Centred Management of Stable COPD in Primary Care
HOLISTIC
CARE
Check social
Support
(e.g. carers
benefits)
Treat
co-morbidities.
All PATIENTS
Smoking cessation advice
Patient education/self management
Assess co-morbidity
ASSESS BMI: Dietary Advice >25 , Specialist Dietary Referral if BMI <20
Exercise promotion
Pneumococcal vaccination
Annual influenza vaccination
How does this fit in everyday
management?
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What evidence have we got so
far?
• NOT A LOT!
Managing patients with multimorbidity:
systematic review of interventions in
primary care and community settings
BMJ 2012; 345 doi:
http://dx.doi.org/10.1136/bmj.Susan M Smith,
associate professor of general practice1, Hassan Soubhi, adjunct
professor of family medicine2, Martin Fortin, professor of family
medicine2, Catherine Hudon, associate professor of family
medicine2, Tom O’Dowd, professor of general practice3
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What evidence have we got so
far? • 10 studies looking at interventions in
primary care settings
• 8 out of 10 studies US
• ORGANISATIONAL(Multidisciplinary
team, education , drug review(including
pharmacist)
SELF MANAGEMENT : education ,
structured self-mangement
What evidence have we got so
far?
• Results mixed.
• Some evidence of improvements in
specific areas e.g medicines management
• Results ? Better when specific co-
morbidity looked at and when look at
functional limitation.
• Paucity of economic studies.
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National Survey of Multi-
morbidity in clinical practice
with COPD as an examplar
Dr Shoba Poduval
Clinical Support Fellow and First5 GP
Survey
• 7 point questionnaire uploaded to survey
monkey
– What did you do? How did you do it?
Why? What prompted you?
– Overall impact -how this benefits patients,
staff and the organisation
– Lessons learnt, what went well? What
didn’t work well? Advice for others
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Survey
• Open 29.11.12 - 8.2.13
• Thirty four responses
• Thirteen reviewed- themes
• Five case studies
• Other Practices of note- telehealth
Preliminary Results
Themes
• Motive
• Patient selection &
invitation
• Organisation
• Staff
• Housebound
patients
• Outcomes
• Evaluation
• Challenges
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Motives
• QoF
• PBC/CCG funding
• Improving patient experience
Patient selection & invitation
• Disease registers
• Disease severity stratification
• Specific patient selection criteria
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Staff
• Practice team: GP’s, Nurses, HCA’s,
admin staff
• Community team: District Nurses,
Community Nurses, Social Services,
Pharmacists
• Secondary Care
Housebound
• Visits by GP’s & Community Matrons
• On-going support from Community Matron
& Social Services
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Outcomes
• Patient and staff satisfaction
• More appointment time available
• Medication adherence
• Reduced A&E attendance
• Projected savings
Challenges
• Training
• Organisation- time
• Resources- templates
• Funding
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Discussion
• What is your experience of managing
multimorbidity?
• Challenges?
• Suggestions?
So What do we do in Practice?
Long term
condition Clinics IHD/Diabetes/ Heart
Failure etc.
Chronic Care Model of
Wagner
(Proactive structured
care, supportive self
manage
Care Planning
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CHALLENGES
• Deciding on the co-morbidities
• Content and Integration of Templates
• Management of Housebound
• Medicines Management Review
• Stratifying Risk and use of Community
Teams.
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