Multimorbidity, the coexistence of two or more chronic health conditions, is a significant challenge in modern medicine, especially for older adults. It often leads to worse health outcomes and quality of life. Hospital care systems are not always equipped to handle patients with multiple conditions, as healthcare workers typically specialize in single diseases. This study highlights the need for a holistic approach to treating multimorbidity in hospitals. Research into multimorbidity has primarily focused on primary care and population data, leaving a gap in understanding how these patients are managed in hospitals. The study also discusses the complexities of treating multiple conditions, which can lead to polypharmacy (using multiple medications) and additional health risks. To improve care, it’s essential to move away from a single-disease focus and consider the interactions between conditions.
Abstract
Multimorbidity (sometimes referred to as multiple long-term conditions; MLTC) refers to the coexistence of two or more chronic health conditions and has been described as posing one of the greatest challenges to medicine and science in the twenty-first century [1]. There are many conditions that modern medicine cannot cure, and until this changes, conditions will accumulate across the life course with older people facing the highest burden of multimorbidity [2, 3]. The prognosis of people with multimorbidity is considerably worse than prognosis of people with single conditions, especially if the set of conditions a person is living with includes mental health conditions [4]. A higher burden of symptoms and care, a greater chance of functional decline and worse quality of life are all consequences of multimorbidity [5]. These problems are compounded by a plethora of clinical guidelines that focus on the diagnosis and management of single conditions in isolation [6, 7].
This is particularly true for hospital-based care. Many components of hospital care are not designed or equipped to deliver care efficiently and effectively for people living with multimorbidity. Healthcare workers in secondary care typically specialise in single organ-based diseases and may lack the skills to manage conditions affecting other organs or to understand the impact of other conditions on the index condition. Although geriatricians have generalist skills and processes designed to manage MLTC in hospital, the scale of multimorbidity is such that a whole-system approach is needed to improving hospital care across all specialties. Patients with multimorbidity admitted to hospital constitute a distinct and select subset of people living with multimorbidity—they are by definition unwell enough to require hospital admission, and the patterns, mechanisms and prognosis of their multimorbidity may differ from the general population.
Most research into multimorbidity to date has used large primary care or population-level data sets. We therefore lack important information about how patients with multimorbidity present to, or are managed by, secondary care services. Conducting research into multimorbidity in patients admitted to hospital requires overcoming a series of key challenges, some of which are listed in Table 1. Importantly, if we are to fully understand and improve care for people with multimorbidity admitted to hospital, a single-disease silo approach to research is inappropriate. A particular challenge is that conditions interact with each other, in terms of predisposition to disease, disease presentation and prognosis. Multimorbidity can lead to multiple therapeutic interventions and is a key driver of polypharmacy. Polypharmacy in turn magnifies the risk of side effects and of precipitating further medication-induced conditions. Furthermore, shared biological processes may drive the occurrence and progression of several long-term conditions—a focus on individual diseases, rather than on these underlying common mechanisms, means that we may miss opportunities to treat multiple conditions with the same intervention.
Authors: Miles D Witham, Rachel Cooper, Paolo Missier, Sian M Robinson, Elizabeth Sapey, Avan A Sayer
