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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Defining multiple morbidity
DEFINING COMORBIDITY AND UNDERSTANDING PATIENTS’NEEDS
Faultlines between co-morbidity and multimorbidity
A step in the right direction
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Martin C Gulliford, London UK Professor of Public Health, King's College London UK
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Dr Jose M Valderas and colleagues present a thoughtful analysis of the concepts of comorbidity and multiple morbidity. They demonstrate several difficulties that impede progress towards a concise system of measurement. Two additional points may be made: First, the health care system has an important role in defining multiple morbidity in its clients. In the abstract of the paper, multiple morbidity is defined as the 'coexistence of two or more conditions in a patient'. Conditions are acknowledged to include 'diseases, disorders, conditions, illnesses or health problems' but later sections of the paper refer to co-existent diseases as characterising multiple morbidity. Diseases are defined by diagnoses that may only be conferred on individuals who are able to access medical care. Accessing medical care also leads to the identification and treatment of risk factors such as hypertension and hypercholesterolaemia but it is unclear whether these, and related risk states such as prediabetes, prehypertension or components of the metabolic syndrome, merit classification as 'morbidities'(1). Meanwhile, the perceived relevance of patient-experienced problems, such as back pain or tinnitus, is unclear. Secondly, current approaches to defining multiple morbidity commonly utilise counts of the numbers medical diagnoses in each patient (see for example, Fortin et al (2), Figure 1). After a lifetime of interaction with the health care system, most individuals have accumulated a number of diagnoses of long-term conditions, some of which may have trivial present impact. The reviewers point out that the severity, as well as the number of conditions, is an essential component of a useful definition of multiple morbidity. This is exemplified in the scoring of the Cumulative Illness Rating Scale(3) in which conditions affecting each bodily system are rated on a scale where zero represents 'no problem affecting that system' and four represents an 'extremely severe problem, and/or immediate treatment required, and/or organ failure, and/or severe functional impairment'. The Charlson Index(4) is also widely used, but this was developed to predict the one-year mortality of hospital inpatients and may be less suitable for community studies(5). More generally, the meaning of 'severity' and the criteria to be used in defining the severity of co- existing conditions in ways that are relevant to different contexts require clarification. Martin Gulliford King's College London, Department of Public Health Sciences References
Competing interests: None declared |
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Hilde Luijks, Nijmegen, The Netherlands Department Primary and Community Care, Radbuoud University, Toine Lagro-Janssen, Chris van Weel
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In ageing populations, there is an increase in the number of patients with more than one important health problem present at the same time: comorbidity or multi morbidity. As a consequence, comorbidity has a profound impact on patient care, and on the planning and structuring of health care services. Valderas et al [1] analyzed the literature of comorbidity and concluded that the concepts and definition of what comorbidity is, depends on the context in which it is encountered. They distinguish in this respect between clinical care, epidemiology and health services planning. In the primary care population and under patients encountered in family practice, a large minority are under treatment for two or more chronic diseases [2, 3]. Currently, in the support of patient care and clinical decisions, a disease-specific approach dominates, with condition- specified quality and outcome criteria [4]. In this approach, ‘comorbidity’ heralds particular facts that may force clinicians to deviate from their disease specific delineation [5]. With ‘comorbidity’ a rule rather than an exception, it is in our view no longer acceptable to apply for patients with more than one chronic disease an ‘opt-out of standard practice’ approach. For that reason, it is important to develop a better understanding of comorbidity, as a universal patient characteristic. This common ground is what would lend importance of comorbidity in the context of patient care, epidemiology and health care services [1]. A more in-depth exploration of patient care and the underlying clinical decision making may help to get more insight in the nature of comorbidity. Although the research evidence of comorbidity is limited, practitioners demonstrate a systematic difference in their treatment of patients with and without comorbidity – and practice appears to be well ahead of science. An interesting example in this respect is provided by a recent study in the UK of the management of patients with depression [6]. Family physicians (FP) arranged for more care, when the depression was more severe. But this needs dependent approach was less clear in patients with chronic physical comorbid conditions, who in general received less interventions than patients with depression as their only condition. An interpretation of these findings could be that FPs are reluctant to add-on interventions [7]. This is in particular the case in prescribing multiple drugs because of patient compliance and potential interactions [5]. Generic interventions such as empowerment and lifestyle changes may be more attractive because they may treat more than one condition at the same time [8]. Next to the health problem as such, FPs explore in their encounters patients’ preferences, interests and expectations around their health problems. These patients’ preferences may often conflict with or be incompatible to, plain disease-centered reasoning and this will influence FPs’ clinical decision. Everyday practical examples are the aversion of medication, priority for pain reduction over causal treatment or preference for a non-demanding , non-embarrassing therapy. In reconciling the implications of disease status and patient preferences, the true FP decisions are made. And FPs have a professional opinion on what the disease status demands as well as what patients prefer. The depression study as a case in point stresses the need of gaining better insight in the process in of decision making . Exploration of the practical experience should focus on the aims and objectives patients and FPs have in seeking and prescribing care. This would change the determination of patients’ needs beyond the disease perspective to a patient, or person, centred approach. Critical is the notion that a person centered approach is more than just pleasing the patient or merely prescribing his or her expressed preferences. Expectations and perceived needs are formed from patients’ and families’ medical life experience [9] – as different consecutive, or as co-existing, episodes of illness experienced. This is the experience they bring to the practice, and the ‘healing relation’ between patient and FP [10] is determined by the FPs’ responsiveness. That is how, in our view, comorbidity shapes the process and outcome of care. It is time to come to a much better understanding of how the different disease scripts and the individual context interact into clinical decisions that flow from it – on patient care, for the provision of health care services and on the epidemiology. References
1. Valderas JM, Starfield B, Sibbold B, Salisbury C, Roland M. Defining
Comorbidity: Implications for Understanding Health and Health Systems.
AnnFamMed 2009; 7: 357-363.
Competing interests: None declared |
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Tom O'Dowd, Dublin, Ireland Prof of General Practice, Trinity College Dublin, Susan Smith
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Establishing A Faultline Between Co-Morbidity and Multi-Morbidity Valderas et al (Annals of Family Medicine July/August 2009) point out that there is no general agreement on the meaning of the term ‘co-morbidity’ and related constructs such as multi-morbidity. Clinical practice is fraught with definitional difficulties and it is important, especially in the area of international research, that we have a strong conceptual approach and good working definitions for enrolment into managed care programmes and clinical trials. The current interest in multimorbidity in primary care represents a focus for academics and researchers anxious to contribute at population and clinical levels. Valderas and colleagues provide an important insight in pointing out that co-morbidity has an emphasis on an index disease which is particularly useful in specialist care which has a strong orientation towards a single disease, or a single diseased system. Multimorbidity on the other hand focuses on the patient as a whole without emphasis on any single condition. This insight represents an important difference between specialist and primary care in the approach to chronic disease management. Much of the enthusiasm for multimorbidity in primary care research is that it echoes the reality of clinical practice. In the July issue of the Annals, Stange and Ferrer, point out that primary care is associated with apparently poorer quality of care for individual diseases but paradoxically with similar functional outcomes, better quality health and greater equity for communities and populations than specialist care. They call it the primary care paradox. Is it that ‘good enough’ primary care makes all the difference? The faultline between co-morbidity and multimorbidity is an important one. Co-morbidity is intuitive, predictable and can aggregate specialists and technology around it. It can also, to paraphrase Julian Tudor Hart, remain unsullied by community and societal concerns. Multi-morbidity is the reality of clinical life in primary care and the definitional challenges posed by co-morbidity pale are fewer when it comes to multimorbidity. It does however represent intellectual and professional challenges for us to place our mark on the chronic illness map. It provides an opportunity for primary care to outline the scope and scale of our role to payers and patients alike. The paper by Valderas et al demonstrates that much more work needs to be done in developing the patient perspective in terms of social, physical and psychological constraints. Outcome measurement is more of a challenge in multimorbidity than in co-morbidity where at least specific diseases can be the focus. Co-morbid conditions share aetiological or risk factors whereas multimorbidity incorporates additional management challenges such as the treatment for one condition exacerbating another. We are nonetheless on the way in primary care in explaining the potential of cost-effective, equitable, competent, clinical care for common chronic diseases that affect the majority of our patients. Tom O'Dowd & Susan Smith
Competing interests: Engaged in research on multimorbidity |
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Martin Fortin, Saguenay, Canada Family doctor and researcher, Université de Sherbrooke
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Thank you for this work around the concepts of comorbidity and multimorbidity. This is really a step in the right direction. I believe like you that the lack of a clear consensual definition and measure of comorbidity/multimorbidity and related constructs is an impediment to research and it is particularly important in primary care where the prevalence of multimorbidity is so high in the attending population.1 The concepts still need a bit of disentangling but you did a great work. Several points came to my mind while reading your paper and I will summarize them in the following paragraphs. Nature of health conditions. There is still no consensus about what ought to be included in a count of chronic diseases. On an epidemiological perspective, the number of diagnoses accounted for influences enormously the results of prevalence studies. Should we rely on the World Health Organization definition of a “chronic disease” or on a specific classification? How do we handle multiple diagnoses within the same system? Should related conditions be counted separately of be considered as a whole? Anxiety, depression and substance abuse: one mental illness or three? Angina pectoris, previous myocardial infarction, atrial fibrillation and heart failure: one cardiovascular disease or four? No clear consensus on that. How about conditions considered as risk factors but requiring specific management like hyperlipidemia, obesity? Those examples demonstrate the importance of defining precisely the intention behind the simple count of chronic conditions. So I agree with you that from an epidemiological and public health perspective, the measurement approaches should be based on counts but it’s really important to define precisely what is to be counted and for what purpose. Severity. I was surprise not to see “severity” as an important construct in the figure 2. Severity may be conceptualized at the disease level or at the patient level. At the disease level, it’s part of the disease process. An example would be a mild hypertension that only requires a small dose of diuretic compared with a more severe hypertension requiring 3 different drugs. At the patient level, it’s also part of the disease process but it’s linked to the impact on function or other outcomes. An example would be mild asthma versus severe asthma with important limitations. You acknowledged that severity contributes to the disease burden and patient’s complexity. In this regard, it could have been included in the figure 2. Maybe instead of frailty that is more specific for elderly and could have been included within the “other health -related individual attributes”. This article makes an important contribution to the research field. It clarifies many issues. As the research is moving forward, the attributes and limits of the constructs will have to be adapted and I agree with you that future research would benefit from using explicit definitions of the constructs in conjonction with established classification systems to favour generalizability and precision. 1. Fortin M, Bravo G, Hudon C, Vanasse A, Lapointe L. Prevalence of multimorbidity among adults seen in family practice. Ann Fam Med 2005;3:223-8. Competing interests: None declared |
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