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Library of Congress Cataloging-in-Publication Data
ABC of multimorbidity / [edited by] Stewart Mercer, Chris Salisbury, Martin Fortin.
p.; cm.
Includes bibliographical references and index.
ISBN 978-1-118-38388-9 (pbk.)
I. Mercer, Stewart, 1957- editor of compilation. II. Salisbury, Chris, editor of compilation. III. Fortin,
Martin, 1960- editor of compilation.
[DNLM: 1. Chronic Disease. 2. Comorbidity. 3. Primary Health Care. WT 500]
RC537
616.85′27--dc23
2014003059
A catalogue record for this book is available from the British Library.
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Cover image: iStockphoto.com, © 2011 Dean Mitchell
Cover design by Andy Meaden.
Clinicians and researchers from all over the world have been interested in the phenomenon of multimorbidity for more than 30 years. Interest in this topic has probably arisen because of a growing tension between two opposing developments. On the one hand, medicine is becoming ever more specialized. Attempts to improve the quality of care have led to a focus on managing care of individual long-term conditions in a very structured and standardized way. On the other hand, there is an increasing awareness that this trend may not be appropriate for people who have multimorbidity. These people are frequent users of health care, and they therefore account for a high proportion of health service contacts in both primary and secondary care. There is an increasing dissonance between the way that health services are designed and the needs of the patients that they serve.
In this book, we seek to explore some of these issues, which provide a fundamental challenge to almost every aspect of medicine from national policy about how health care should be provided to the conduct of each individual consultation between a patient and their doctor. We will discuss research on the prevalence of multimorbidity and factors associated with this. Subsequent chapters consider how multimorbidity has an impact on patients, the relationship between physical and mental health problems and how managing multiple health problems concurrently can create a heavy burden of treatment for patients. At a general practice level, we will discuss the implications of an awareness of multimorbidity for the ways in which consultations are managed, how practices are organized, the design of medical records systems and how to ensure high-quality care. At a health care system or policy level, we will provide evidence about the relationship between multimorbidity and the costs of providing care and consider the implications of multimorbidity for health policy and how health systems should be designed. Finally, we look into the future and think about how we can best improve health care in order to achieve the best possible outcomes for patients.
At the heart of this book is the authors' shared conviction that health care should be person-centred. That is, it should be designed as far as possible to understand and respond to the needs of each unique individual patient to treat people rather than diseases. This approach means that we cannot understand and manage long-term conditions in isolation. We have to understand the wider context, particularly recognizing that many patients with long-term conditions have other conditions as well and these may have important implications for management and prognosis.
Due to space limitations each chapter does not cite all references behind the chapter, but that the lead author of each chapter is happy to provide a full list of references on request.
The photographs in this book are from a public exhibition of photographs illustrating the day to day work of general practitioners in a variety of communities in Ireland. Professor Tom O'Dowd commissioned the photographer Fionn McCann to carry out the photography. We thank Trinity College Dublin for permission to use the photographs.
Stewart Mercer
Chris Salisbury
Martin Fortin
There's nothing unusual about Albert. A patient of mine for many years, he has coronary artery disease, hypertension, hyperlipidaemia, diabetes mellitus, chronic kidney disease, osteoarthritis of the hip and – perhaps unsurprisingly – depression. His case is so typical that every General Practitioner will recognize him or have a patient with a similar selection of medical problems.
And yet whilst he is far from unusual and whilst there are more people in the UK with two or more long-term conditions than there are with one long-term condition, you would never think this was the case when you consider how so much of health care is organized.
Dealing with multimorbidity is complex, and yet most consultations, both in primary and secondary care, still have short consultations, much more appropriate for the single and straightforward. Much of the health service is organized around single conditions – look at the plethora of single-condition specialties. Look at the organization of much medical education – focused on single conditions. Look at the fragmentation of care that results. Look at the powerful impact on patients, who all too often feel as if they are treated as diseases in a person rather than a person with diseases.
Look at research, which frequently excludes patients with multiple morbidities because they make the science too complex. Look at the guidelines, which are so often focused on single conditions, mainly because they are based on the research that excluded the comorbidities. Look at the potential harms of polypharmacy. Look at the difficulty of deciding what ‘good’ looks like in a case like Albert's. It certainly isn't a question of treating the multiple conditions summatively – or life becomes nothing but tablets and tests.
Is it any wonder that doctors find multimorbidity complex and frequently stressful to deal with? Multimorbidity becomes a challenge for the doctor, a challenge for the patient and a challenge for the system. And in a world that talks the mantra of patient-centredness whilst frequently failing to deliver it, it becomes ever more important that we understand multimorbidity.
This book brings a wonderfully welcome, timely and important focus to this extraordinarily important topic. It may even bring a real opportunity to renew relationships between specialist and generalist doctors, who bring such different but complementary skills to our patients. Understanding multimorbidity will bring real dividends to health care. Our patients deserve nothing less.
Professor David Haslam CBE
FRCGP FRCP FFPH FAcadMed (Hon)
Chair, National Institute for Health and Care Excellence