What I learnt at the Primary Health Care Research Conference July 2013, by Andrew Knight

Multimorbidity

I have had trouble understanding the fuss about multimorbidity. Don’t GPs just handle multimorbidity every day?

Martin Fortin helped me understand the issue better. Confronted with a patient with multiple conditions he asked himself “Am I treating this patient with multimorbidity in the best way?”

He found himself unable to answer this question and this led to his research career. Thinking about it this way helped me to understand the challenge of multimorbidity. Clinical GPs who deal with MM every day may find the question fades into the wallpaper. We do it all the time but are we doing the best for these patients?

Fortin has detected a 15% increase in MM 2005 to 2013. Only generalists are interested in multimorbidity! Diseased based approaches tend to capture research funding but it is in proper treatment of MM that the major gains will lie.

A major theme of this conference was the struggle to find a way to think about and analyse multimorbidity that can lead to interventions to improve care in an evidence-based way. We have not yet cracked this nut!

Thoughts on MM

• You can’t design a MM guideline because every patient is unique….(attributed in some form to Martin Roland)
• There are common clusters of chronic diseases and one could design guidelines to match. There were a few presentations on how we might analyse clusters. Quickly becomes incredibly complex as you add diseases.
• MM requires “skill” based guidelines – eg the skill to really implement the patient centred clinical method (my interpretation of John Litts comment) eg the skill to work with a patient to produce a coherent care plan covering all conditions.

Dale Ford

we need to think harder about this problem and ready unpick it. What is it about MM that is the problem? Some conditions interact more than others eg depression and diabetes, compared with say breast cancer and diabetes. Is this important? Is it mainly poly pharmacy that is the problem of MM?

My thoughts…

Some combinations are multipliers (eg diabetes and depression), and some are dividers (eg diabetes and vascular disease boil down to a single management problem)

Is multimorbidity the cause of the “paradox of primary care”?

“the paradox is that compared with specialty care or with systems dominated by specialty care, primary care is associated with the following: (1) apparently poorer quality care for individual diseases, yet (2) similar functional health status at lower cost for people with chronic disease, and (3) better quality, better health, greater equity, and lower cost for whole people and populations.”

Strange and Ferrer. Ann Fam Med July 1, 2009 vol. 7 no. 4 293-299

Andrew Knight, July 2013
Andrew Knight MBBS, MMedSci(ClinEpid), FRACGP, is Chair, Expert Reference Panel on Access, The Australian Primary Care Collaborative, The Improvement Foundation, Adelaide, South Australia, and a general practitioner, Katoomba, The Department of General Practice, The University of Sydney at Westmead Hospital, Sydney, New South Wales.